WHAT YOU SHOULD KNOW
If you have a headache, you’re not alone. Nine out of ten Americans suffer from headaches. Some are occasional, some frequent, some are dull and throbbing, and some cause debilitating pain and nausea.
What do you do when you suffer from a pounding headache? Do you grit your teeth and carry on? Lie down? Pop a pill and hope the pain goes away? There is a better alternative.
New research shows that spinal manipulation – the primary form of care provided by doctors of chiropractic – may be an effective treatment option for tension headaches and headaches that originate in the neck.
A report released in 2001 by researchers at the Duke University Evidence-Based Practice Center in Durham, NC, found that spinal manipulation resulted in almost immediate improvement for those headaches that originate in the neck, and had significantly fewer side effects and longer-lasting relief of tension-type headache than a commonly prescribed medication.
Also, a 1995 study in the Journal of Manipulative and Physiological Therapeutics found that spinal manipulative therapy is an effective treatment for tension headaches , and that those who ceased chiropractic treatment after four weeks experienced a sustained therapeutic benefit in contrast with those patients who received a commonly prescribed medication.
To get to the bottom of the problem, you first need to find out what is causing your pain. Headaches have many causes or “triggers.” These may include foods, environmental stimuli (noises, lights, stress, etc.) and/or behaviors (insomnia, excessive exercise, blood sugar changes, etc.). About 5 percent of all headaches are warning signals caused by physical problems.
Ninety-five percent of headaches are primary headaches, such as tension, migraine, or cluster headaches. These types of headaches are not caused by disease. The headache itself is the primary concern.
“The greatest majority of primary headaches are associated with muscle tension in the neck,” says Dr. George B. McClelland, a doctor of chiropractic from Christiansburg, VA, and chairman of the American Chiropractic Association’s (ACA) Board of Governors. “Today, Americans engage in more sedentary activities than they used to, and more hours are spent in one fixed position or posture. This can increase joint irritation and muscle tension in the neck, upper back and scalp, causing your head to ache.”
What Can You Do?
The American Chiropractic Association’s (ACA) suggests the following:
If you spend a large amount of time in one fixed position, such as in front of a computer, on a sewing machine, typing, or reading, take a break and stretch every 30 minutes to one hour. The stretches should take your head and neck through a comfortable range of motion.
Low-impact exercise may help relieve the pain associated with primary headaches. However, if you are prone to dull, throbbing headaches, avoid heavy exercise. Engage in such activities as walking and low-impact aerobics .
Avoid teeth clenching. This results in stress at the temporomandibular joints (TMJ) – the two joints that connect your jaw to your skull – leading to TMJ irritation and a form of tension headaches.
Drink at least eight 8-ounce glasses of water a day to help avoid dehydration, which can lead to headaches.
In addition, the ACA and its Council on Nutrition suggest you avoid the following food “triggers”:
Avoid caffeine. Foods such as chocolate, coffee, sodas and cocoa contain high levels of the stimulant.
Avoid foods with a high salt or sugar content. These foods may cause migraines, resulting in sensitivity to light, noise, or abrupt movements.
Avoid drinking alcoholic beverages. These drinks can dehydrate you and cause headache pain.
Other headache sufferers may want to avoid not only caffeine, but also high-protein foods, dairy products, red meat and salty foods.
What Can a Doctor of Chiropractic Do?
Dr. McClelland says your doctor of chiropractic may do one or more of the following if you suffer from a primary headache:
Perform spinal manipulation or chiropractic adjustments to improve spinal function and alleviate the stress on your system.
Provide nutritional advice, recommending a change in diet and perhaps the addition of B complex vitamins.
Offer advice on posture, ergonomics (work postures), exercises and relaxation techniques. This advice should help to relieve the recurring joint irritation and tension in the muscles of the neck and upper back.
“Doctors of chiropractic undergo extensive training to help their patients in many ways– not just back pain,” says Dr. McClelland. “They know how tension in the spine relates to problems in other parts of the body, and they can take steps to relieve those problems.”
If your headache is symptomatic of a health problem that needs the care of another discipline, your doctor of chiropractic will refer you to an appropriate specialist.
WHAT YOU SHOULD KNOW
Migraine headaches typically affect one side of the head. They can last anywhere from a few hours to a few days. Some people get them weekly, others have fewer than one a year. Migraines, which usually begin sometime between the teen years and the age of 40, can be classified as either “classic” or “”common.” Migraine headaches can often leave the recipient feeling depressed, out of control, and totally overwhelmed.
Recent scientific developments are providing some answers to the cause. What the researchers are discovering is that migraines are not just a headache. Migraines were once believed to be a disorder of anxious, neurotic women whose blood vessels overreacted. While there is a vascular component, migraines are most likely neurobiological disorders of the brain. There is still much to discover and understand about migraines; however, progress is being made.
You may know you are going to have a migraine before the headache starts. Warning signs include nausea, vomiting, and sensitivity to noise, light, or smells. Classic migraines begin with warning signs such as flashing lights or colors. You may feel as though you are looking through a tunnel. One side of your body may feel prickly, hot, or weak. These warning signs last about 15 to 30 minutes and are followed by pain in your head. Common migraines do not have the same warning signs. However, you may feel tired, depressed, restless, or talkative for 2 or 3 days before the headache starts.
What Can You Do?
At Holmes Spine & Sport Chiropractic, we are dedicated to providing relief from your migraines. It’s believed 70-80% of migraines are triggered from upper neck problems that affect the lower motor neurons that in turn affect the upper motor neurons in the brain leading to migraines. If we can correct problems in the cervical spine you can decrease or potentially eliminate your migraines.
Our treatment guidelines are as follows
Corrective chiropractic treatment of the spine and temporal mandibular joints (TMJ) using chiropractic, massage, and exercise rehab.
Medications. Moderation is the key, many of them can cause rebound headaches if taken too frequently. Be aware of the potential for rebound with each medication you take. (Medications will need to be prescribed by your MD.)
Avoid triggers. Use a headache diary to identify triggers such as certain foods, stress, postural positions, time of day, month, or year, lack of sleep, etc.
Cervical Degenerative Disc Disease
Cervical disc degeneration is a common cause of neck pain, most frequently felt as a stiff neck. Cervical degenerative disc disease is much less common than disc degeneration in the lumbar spine because the neck generally is subjected to far less torque and force. Nonetheless, a fall, whiplash or a twisting injury to the disc space can spur degeneration, and accumulated wear and tear on the disc over time can also lead to neck pain caused by disc degeneration.
Cervical degenerative disc disease pain and symptoms
In addition to having the low-grade pain of a stiff or inflexible neck, many patients with cervical disc degeneration have numbness, tingling, or even weakness in the neck, arms, or shoulders as a result of nerves in the cervical area becoming irritated or pinched. For example, a pinched nerve root in the C6-C7 segment could result in weakness in the triceps and forearms, wrist drop and altered sensation in the middle fingers or fingertips.
Cervical disc degeneration can also contribute to spinal stenosis, and other progressive conditions, as well as a more sudden disc herniation.
Cervical degenerative disc disease diagnosis
Successful diagnosis of cervical degenerative disc disease begins with a physician reviewing the patient’s history of symptoms and performing a physical examination to measure neck extension and flexibility. During the exam, patients may be asked to perform certain movements and report whether the neck pain increases or decreases.
If a physical exam warrants further investigation, imaging studies such as X-Ray, MRI and possibly a CT scan will be taken. These diagnostic images can confirm whether and where degeneration is occurring, and can identify other conditions (such as calcification or arthritis) that could be causing the symptoms.
Cervical degenerative disc disease treatment
The general treatment is largely the same as for degenerative disc disease in the lumbar spine. That is, conservative care (no-surgical) is recommended as the primary strategy and surgery is only considered if a concerted effort at conservative care fails to provide adequate pain relief or a patient’s daily activity has been significantly compromised.
Chiropractic manipulation can relieve low back pain by taking pressure off sensitive nerves or tissue, increasing range of motion, restoring blood flow, reducing muscle tension, and, like more active exercise, promoting the release of endorphins within the body to act as natural painkillers
Over the counter and prescription medications may provide relief. These include non-steroidal anti-inflammatories (NSAIDs) and pain relievers like acetaminophen (such as Tylenol). Prescription medications such as oral steroids, muscle relaxants or narcotic pain medications may also be used.
Exercise, specifically stretching as many dimensions of the neck as possible,is essential to maintain flexibility in the neck and relieve chronic stiffness. A specific set of exercises should be developed by a physician or physical therapist. Some exercises that could be done several times a day include:
Chin-to-chest stretch, which stretches the back of the neck
Side-to-side swivel, which involves slowly turning the head to the left and right
Eyes-to-the-sky, where a patient lifts the chin upward to stretch the front of the neck and upper thoracic area
Ear-to-shoulder stretch to extend the sides of the neck as much as possible (this can be facilitated by gently placing a hand on the head but should not involve pulling or pushing the neck and head to the shoulder)
Use of a cervical pillows or neck traction may also be recommended to stabilize the neck and improve neck alignment so the disc compression is not exacerbated as a patient sleeps or relaxes at home
If pain is not relieved adequately or daily activities become difficult, surgery may be considered.
Cervical Herniated Disc
Cervical herniated disc symptoms and treatment options
Cervical herniated disc introduction
Arm pain from a cervical herniated disc is one of the more common cervical spine conditions treated by chiorpactors. It usually develops in the 30 – 50 year old age group. Although a cervical herniated disc may originate from some sort of trauma or injury to the cervical spine, the symptoms, including arm pain, commonly start spontaneously.
The arm pain from a cervical herniated disc results because the herniated disc material “pinches” or presses on a cervical nerve, causing pain to radiate along the nerve pathway down the arm. Along with the arm pain, numbness and tingling can be present down the arm and into the fingertips. Muscle weakness may also be present due to a cervical herniated disc.
The two most common levels in the cervical spine to herniate are the C5 – C6 level (cervical 5 and cervical 6) and the C6 -C7 level. The next most common is the C4 – C5 level, and rarely the C7 – T1 level may herniate.
The nerve that is affected by the cervical disc herniation is the one exiting the spine at that level, so at the C5-C6 level it is the C6 nerve root that is affected.
Symptoms of a cervical herniated disc
A cervical herniated disc will typically cause pain patterns and neurological deficits as follows:
C4 – C5 (C5 nerve root) – Can cause weakness in the deltoid muscle in the upper arm. Does not usually cause numbness or tingling. Can cause shoulder pain.
C5 – C6 (C6 nerve root) – Can cause weakness in the biceps (muscles in the front of the upper arms) and wrist extensor muscles. Numbness and tingling along with pain can radiate to the thumb side of the hand. This is one of the most common levels for a cervical disc herniation to occur.
C6 – C7 (C7 nerve root) – Can cause weakness in the triceps (muscles in the back of the upper arm and extending to the forearm) and the finger extensor muscles. Numbness and tingling along with pain can radiate down the triceps and into the middle finger. This is also one of the most common levels for a cervical disc herniation
C7 – T1 (C8 nerve root) – Can cause weakness with handgrip. Numbness and tingling and pain can radiate down the arm to the little finger side of hand.
It is important to note that the above list comprises typical pain patterns associated with a cervical disc herniation, but they are not absolute. Some people are simply wired up differently than others, and therefore their arm pain and other symptoms will be different.
Since there is not a lot of disc material between the vertebral bodies in the cervical spine, the discs are usually not very large. However, the space available for the nerves is also not that great, which means that even a small cervical disc herniation may impinge on the nerve and cause significant pain. The arm pain is usually most severe as the nerve first becomes pinched.
Treatments for a cervical herniated disc
The majority of the time, the arm pain from a cervical herniated disc can be relieved through conservative care. .
Once the arm pain does start to improve it is unlikely to return, although it may take longer for the weakness and numbness/tingling to improve. If the arm pain gets better it is acceptable to continue with conservative treatment, as there really is no literature that supports the theory that surgery for cervical disc herniation helps the nerve root heal quicker.
All treatments for a cervical herniated disc are essentially designed to help resolve the arm pain, and usually the weakness and numbness/tingling will resolve with time.
Diagnostic tests for a cervical herniated disc
After the initial exam, special diagnostic imaging tests may be required to better diagnose a cervical herniated disc.
MRI Scan to identify a cervical herniated disc
The single best test to diagnose a herniated disc is an MRI (Magnetic Resonance Imaging) scan. An MRI scan can image any nerve root pinching caused by a herniated cervical disk.
CT scan with myelogram to identify a cervical disc herniation
An MRI is the best first test, although occasionally a CT scan with a myelogram may also be ordered, as it is more sensitive and can diagnose even subtle cases of nerve root pinching.
Although a CT scan with myelogram is more sensitive it is also a slightly invasive test, as the myelogram dye must be injected into the spinal canal as part of the procedure. Because of the injection, a CT scan with myelogram is not usually the first test ordered.
Plain CT scans (without myelogram) are for the most part not useful for the diagnosis of a herniated cervical disc.
EMG to identify other conditions causing pain
Occasionally, an EMG (Electromyography) may also be requested. An EMG is an electrical test that is done by stimulating specific nerves and inserting needles into various muscles in the arms or legs that may be affected from a pinched nerve. If the muscles have lost their normal innervation, there will be spontaneous electrical activity.
An EMG can also help rule out other nerve entrapment syndromes that can give one arm pain, such as carpal tunnel syndrome, brachial plexitis, ulnar nerve entrapment, thoracic outlet syndrome, among other conditions.
Conservative treatment for a cervical herniated disc
First line of treatment for a cervical herniated disc
When the initial pain from a cervical herniated disc hits, anti-inflammatory medications such as ibuprofen (e.g. Advil, Nuprin, Motrin) or COX-2 inhibitors (e.g. Celebrex) can help reduce the pain.
The pain caused by a cervical herniated disc is caused by a combination of: 1) pinching of the nerve root, and; 2) inflammation associated with the disc material itself. Therefore, taking anti-inflammatory medications to remove some of the inflammation can reduce this component of the pain while the pressure component (pinching of the nerve root) resolves.
Additional conservative treatment options for a cervical herniated disc
In addition to anti-inflammatory medications, there are a number of non-surgical treatment options that can help alleviate the pain from a cervical herniated disk, such as:
Chiropractic manipulation. Manipulation can help reduce the joint dysfunction that may be an added component of the pain. In the initial period your chiropractor also opt to use modalities, such as heat/ice or ultrasound, to help reduce muscle spasm and lessen referred arm pain.
Massage. Massage can treat active trigger points in the muscle that are producing pain and spasm.
Spinal Decompression or Cervical Traction. Traction on the head can help reduce pressure over the nerve root. It does not work for everyone but is easy to do, and if effective the patient can use a home traction device for pain from a cervical herniated disc.
Physical therapy / exercise rehab. Just as in the lumbar spine, Mckenzie exercises can be used to help reduce the pain in the arm.
Activity modification. Some types of activities may tend to exacerbate the herniated disc pain and it is reasonable to avoid these activities to keep from irritating the nerve root. Such activities may include heavy lifting (over 50 pounds), activities that can cause increased vibration and compression to the cervical spine (boating, snowmobile riding, running, etc.), and overhead activities that require prolonged neck extension and/or rotation.
Bracing. In some instances a cervical collar or brace may be recommended to help provide some rest for the cervical spine.
Medications. In addition to the anti-inflammatory medications mentioned above, narcotic agents (pain killers) might be used on a temporary basis to help reduce the pain and discomfort from a cervical herniated disc. Also, muscle relaxants or certain anti-depressants may help reduce the nerve-type pain (neuropathic pain) and help restore normal sleep patterns. For patients with severe pain from a herniated disc, oral steroids (such as Predisone or a Medrol Dose Pak) may give even better pain relief. However, these medications can only be used for a short period of time (one week).
Injections. Epidural steroid injections or selective nerve root blocks can be helpful to reduce inflammation in cases of severe pain from a cervical herniated disc, and can be effective if accompanied by a comprehensive rehabilitation program that may involve a number of the above conservative treatments.
Surgery. Most episodes of arm pain due to a cervical herniated disc will resolve over a period of weeks to months. However, if the pain and disability is severe, spine surgery may be a reasonable option.
Summary of cervical herniated disc treatment options
Cervical herniated disc typically respond to conservative treatments. For the few cases that don’t respond well surgery can usually provide relief of the pain.
At Holmes Spine & Sport Chiropractic we provide a number of conservative treatments under one roof to treat your cervical disc herniation. We also work with your family physician or orthopedic surgeon assist in getting you any medications or consultations you may need.
Chiropractic and neck pain.
Consulting a chiropractor for neck pain might seem obvious to a patient who has experienced chiropractic and who associates an adjustment with the release of tension, increased motion, and pain relief.
For others, chiropractic treatment of the neck brings to mind a different picture. What could be the benefit of “popping” the bones in the neck? When family doctors are asked about neck manipulation, they often visualize an abrupt twisting of the neck and are apt to sound a note of alarm when a patient seeks chiropractic care for a cervical pain and injury. However chiropractic has shown to be very effective in treating neck pain and injury.
Similar to medical doctors, chiropractors use diagnostic indicators to differentiate types of neck problems. How these indicators are used and what occurs during a cervical adjustment will help to increase awareness of the indications and limitations of chiropractic care for neck conditions.
Chiropractic offers a unique and valuable mechanical approach to a wide range of cervical problems. Chiropractors do not “over twist” the neck or perform painful maneuvers. Manipulation or adjusting as performed by chiropractors is a precise therapy whose aim is to return motion to restricted spinal joints and to improve the overall mechanics of the spine.
Torticollis, also known as cervical lock syndrome or wry neck, presents with a sudden onset of neck pain resulting with head and neck locked to one side.
You may be awakened from sleep by the pain or when you wake up in the morning, you find that you have a stiff and sore neck. The cause could include a proceeding episode of intense activity, sitting in an awkward position for a period of time, sleeping with your neck exposed to an open window or even an air-conditioner. Occasionally you may have had a sore throat or an infection of the pharynx that can precipitate the cause of the stiff and sore neck. Movement of your neck is generally very difficult due to the pain and spasm.
Chiropractic care can be highly effective in unlocking the joints and relaxing the muscles of the neck. Modalities such as moist heat, massage, muscle stimulation, infrared light therapy and ultrasound will also speed the reduction of the spasms. With the proper treatment and within the right time frames this condition responds quickly and favorably. The longer this condition is allowed to persist, the longer the response time will be. Children and infants respond well and usually get their pain and dysfunction resolved with one to two weeks. Adults also respond well but they usually wait longer to seek care and therefore response time may be extended.
Do not wait until your problem gets worse. Underlying causes need to be identified so the correct treatment can be started or to establish if the problem is more serious and needs a referral.
Introduction to whiplash
Whiplash is a term that describes injury to the neck that occurs as a result of a motor vehicle or car accident. The most common type of car accident is the rear impact, and most typically, the occupant in the vehicle that gets “rear-ended” (hit from behind) is at the greatest risk of injury, including whiplash.
Until recently, the reason for the extent of whiplash injury was poorly understood. In addition, due to the legal and insurance issues, the veracity of complaints of neck pain and other symptoms by people who suffer from whiplash is commonly viewed as suspect.
However, recent research has helped clarify why occupants struck from behind experience more extensive whiplash injuries than those in other types of crashes. This new information is important for the physician treating these whiplash problems, as it impacts the physician’s case management strategy.
In fact, whiplash injuries can be quite complex and may include a variety of related problems, such as:
Faulty movement patterns
Cognitive and higher center dysfunction
How does whiplash occur?
When one motor vehicle strikes another from behind, certain forces are transmitted from the striking vehicle to the struck vehicle. These forces are then transmitted to the occupant(s) of the struck vehicle where they have the potential to cause whiplash injury.
Recent research, both in the Biomechanics Laboratory at Yale University in New Haven(1), and in live crash tests using human volunteers(2), has shed new light on the contortions the cervical spine (neck) undergoes as a result of impact and culminating in whiplash.
Shortly after impact (about 150 milliseconds), the cervical spine undergoes what is called an S-shaped curve. In this configuration, the cervical spine, rather than simply being curved to the front in a normal C-shape, as it would normally be at rest, takes on an altered shape:
The lower part of the cervical spine moves into extension (bent backward)
The upper part of the cervical spine moves into flexion (bent forward)
When this whiplash occurs, the lower part of the cervical spine moves well beyond its normal range of motion, causing the potential for injury to the ligaments and discs in that area. The upper part of the cervical spine also moves beyond its normal range of motion, but to a lesser extent.
There is an inherent stabilization response in the cervical spine that helps protect it from potential whiplash injury:
The nervous system detects the presence of the impact; and
The muscles of the cervical spine, under the direction of the nervous system, contract quickly to try to minimize the affects of the impact on the ligaments and discs.
If this stabilization response is working efficiently, there is a greater likelihood of protection against whiplash with less potential for whiplash injury. But if the response is inefficient, whiplash injury is more likely.
Factors affecting the whiplash injury
There are several factors that affect the efficiency of the stabilization response during whiplash, some of which are within our capacity to control, others of which are not. These include:
Posture at impact
Overall physical condition
Awareness of coming impact
How posture at impact affects a whiplash injury
The posture in which a person is sitting at the moment of impact helps determine the efficiency of the stabilization response that will affect the severity of the whiplash injury. Sitting in a correct posture promotes an efficient stabilization response(3). Sitting in a poor posture, particularly a “slumped” type posture, promotes an inefficient stabilization response.
How overall physical condition affects a whiplash injury
The better conditioned the body is in general, the more efficient the stabilization response will be. This particularly relates to the condition of the nervous system, as a well-functioning nervous system is essential to a proper stabilization response.
How awareness of coming impact affects a whiplash injury
Perhaps the most important factor that affects the efficacy of the stabilization response in relation to whiplash is awareness of the impending impact.
Scenario 1: Aware of impending impact. This person is able to automatically prepare the stabilization system to respond quickly and efficiently.
Scenario 2: Unaware of the impending impact. This person cannot prepare the stabilization system, thus slowing the response and decreasing its efficiency. This person is likely to sustain greater whiplash injury than is the person who is aware.
This may help explain the findings of some studies(4, 5) that have shown a passenger in a struck vehicle is likely to sustain greater whiplash injury than the driver. The driver is more likely to see the vehicle coming in the rear view mirror.
How gender affects a whiplash injury
Women in general are more frequently and more seriously injured by whiplash than men due to the differences in muscular bulk and the female’s smaller bony structures. These factors result in less protection of the cervical spine to the abnormal forces such as those that occur in a whiplash-type of injury.
How other factors affect a whiplash injury
Risk factors influencing prognosis of a whiplash injury(6):
Symptoms persisting beyond 6 months. (43% failed to recover on average)
Significant ligament, disc, nerve, or joint capsule injury.
Delay in initiating treatment
Need to resume treatment for more than one flare-up of pain.
Occupant age over 65
Head restraint more than 2″ away from occupant’s head.
Occupant in a small car
Alcohol intoxication at time of automobile accident
Pre-existing x-ray evidence of degenerative changes
Prior whiplash injury
Prior cervical spine fusion
Patient having initial radicular (arm pain, numbness, tingling) symptoms
A cervical collar used for more than 2 weeks
Common misconception about whiplash injury
A common misperception about whiplash injury is that if the vehicle does not sustain damage in a low speed impact, then whiplash injury to the occupant does not occur. In reality, however, low impact collisions can produce correspondingly higher dynamic loading on the occupants because the lack of crushing metal to absorb the forces results in a greater force applied to items or occupants within the vehicle(7, 8).
An important point to remember is if you have been in a motor vehicle accident, you usually won’t feel the threshold of your pain or discomfort until a week or two later. Do not make the mistake of judging the severity of your condition by your pain levels. Even in a low-force crash at speeds as low as 5 mph, individuals can be subjected to whiplash.
Chiropractic techniques and the chiropractor’s skill are particularly suited for correcting and relieving the otherwise debilitating effects of whiplash.
At Holmes Spine & Sport Chiropractic, we are dedicated to restoring your spine to good health by restoring joint movement lost after the accident and strengthening weakened muscles through chiropractic manipulation, massage and exercise rehab. It is possible to prevent chronic or reoccurring pain from injuries suffered during whiplash. The key is not to wait, but start your chiropractic care as soon as possible.
Panjabi MM, Cholewicki J, Nibu K, Grauer JN, Babat LB, Dvorak J. “Mechanism of whiplash injury.” Clin Biomech 1998;13:239-249.
Kaneoka K, Ono K, Inami S, Hayashi K. “Motion analysis of cervical vertebrae during whiplash loading.” Spine 1999; 24(8):763-769.
Murphy DR. ” Normal function of the cervical spine II: Neurophysiology and stability.” In: Murphy DR, ed. Conservative Management of Cervical Spine Syndromes. New York: McGraw-Hill, 1999:45-70.
Harder S; Veilleux M; Suissa S. “The effect of socio-demographic and crash-related factors on the prognosis of whiplash.” J Clin Epidemiol 1998 May;51(5):377-84.
Parmar HV, Raymakers R. “Neck injuries from rear impact road traffic accidents: prognosis in persons seeking compensation.” Injury 1993; 24:74-78.
Nordhoff L: “Motor Vehicle Collision Injury for the 1990’s Doctor/Attorney”, Automotive Injury Research Institute,1994.
Macnab I: “Acceleration Extension Injuries of the Cervical Spine.” Rothman and Simeone, The Spine. 1982.
Hirsch SA, Hirsch PJ, Hiramoto H, “Whiplash Syndrome: Fact or Fiction?” Ortho C1 N Amer,19(4):791-95;1988.
Mid Back Pain
Mid back pain is pervasive among Americans adults, but a new disturbing trend is emerging. Young children are suffering from back pain much earlier than previous generations, and the use of overweight backpacks is a contributing factor, according to the American Chiropractic Association (ACA). In fact, the U.S. Consumer Product Safety Commission reports that backpack-related injuries sent more than 7,000 people to the emergency room in 2001 alone.
This new back pain trend among youngsters isn’t surprising when you consider the disproportionate amounts of weight they carry in their backpacks–often slung over just one shoulder. A recent study conducted in Italy found that the average child carries a backpack that would be the equivalent of a 39-pound burden for a 176-pound man, or a 29-pound load for a 132-pound woman. Of those children carrying heavy backpacks to school, 60 percent had experienced back pain as a result.
The results of these types of studies are especially important as more and more school districts–many of them in urban areas–remove lockers from the premises, forcing students to carry their books with them all day long.
In fact, the problem has become so widespread that the California State Assembly recently passed legislation that would force school districts to develop ways of reducing the weight of students’ backpacks. Similar legislation is being considered in New Jersey as well. The ACA believes that limiting the backpack’s weight to no more than 10 percent of the child’s body weight and urging the use of ergonomically correct backpacks are possible solutions.
What Can You Do?
The ACA offers the following tips to help prevent the needless pain that backpack misuse could cause the students in your household.
Make sure your child’s back pack weighs no more than 5 to 10 percent of his or her body weight. A heavier backpack will cause your child to bend forward in an attempt to support the weight on his or her back, rather than on the shoulders, by the straps.
The backpack should never hang more than four inches below the waistline. A backpack that hangs too low increases the weight on the shoulders, causing your child to lean forward when walking.
A backpack with individualized compartments helps in positioning the contents most effectively. Make sure that pointy or bulky objects are packed away from the area that will rest on your child’s back.
Bigger is not necessarily better. The more room there is in a backpack, the more your child will carry-and the heavier the backpack will be.
Urge your child to wear both shoulder straps. Lugging the backpack around by one strap can cause the disproportionate shift of weight to one side, leading to neck and muscle spasms, as well as low-back pain.
Wide, padded straps are very important. Non-padded straps are uncomfortable, and can dig into your child’s shoulders.
The shoulder straps should be adjustable so the backpack can be fitted to your child’s body. Straps that are too loose can cause the backpack to dangle uncomfortably and cause spinal misalignment and pain.
What is Costochondritis?
Costochondritis is a condition characterized by pain and tenderness along the chest wall, normally very close to the breastbone (sternum). By definition, costochondritis is an inflammation of the juncture of the rib cartilage where the ribs attach to the sternum. While this may seem like a very simple condition, it unfortunately produces extreme pain to the point where individuals feel as if they are experiencing a heart attack or have other internal medical conditions. For this reason, it is not uncommon for individuals to go to the emergency room to rule out more serious conditions.
When other conditions have been ruled out, examination of the chest wall reveals isolated regions of extreme tenderness just off to the sides of the breastbone (sternum). This condition may be made worse with deep inspiration, by compression of the ribcage, or by hard coughing or sneezing. In other words, any event that either compresses or stretches the ribcage may stretch the rib cartilage, thereby producing extra pain.
To make matters more complicated with this condition, costochondritis may stem simply from an inflammation of the cartilage or may be secondary to a mid-back spinal problem. For example, in a growing child who has to wear a heavy backpack, a hunching of the back or a drooping of the shoulders may be seen due to repeated postural alterations. This increased bending of the mid-back may cause compression of the ribs, causing secondary costochondritis. In this instance, chiropractic care to the thoracic spine to increase flexibility of that region, as well as mobilization techniques to the ribs, is of great benefit. At other times, simply stretching the thoracic spine to allow full movement of the rib cage brings sufficient stretch to the rib cartilage to allow the soreness to go away. Sometimes, however, localized soft tissue techniques are utilized over the rib cartilage. Transverse frictional techniques have been shown to be very effective in reducing adhesions or scar tissue that develops in cartilage. Since there is very little blood supply to the cartilage structures throughout the body, it is necessary to break up those adhesions in order for the fibers of that particular tissue to heal.
Whether costochondritis comes from blunt trauma to the chest wall causing localized inflammation, a rib is injured with a twisting incident, or the thoracic spine is involved, chiropractic care normally proves very beneficial in relieving the discomfort. At other times, however, the condition may be very resistant to conservative measures and cortisone injections or anti-inflammatory medication may be needed.
Back pain can come from many causes
If there is no reported direct trauma or injury to the mid back, this type of symptom is usually caused by a spinal joint dysfunction/ misalignment involving one or more of the thoracic vertebra. These joint dysfunctions are typically only diagnosed by chiropractors through a process called palpation or feeling the spine.
Poor posture in many cases is the cause of mid back pain. So in treating mid back pain posture is often evaluated and exercises given to strengthen the core muscles of the body to support better posture.
Another cause of mid back pain is rib involvement. Anatomically, the thoracic spine (middle back) attaches to the ribs. If a blunt force affects the ribs, even if the force occurred in the front part of the body, mid back back pain may be felt because the muscles between the ribs were irritated. Sometimes this can occur when the patient has twisted and bent sideways while lifting or pushing something. Often patients will remark that they have difficulty with full breaths.
Chiropractic is an affective way to treat mid back pain. Treatment will consists of spinal and rib manipulations to the thoracic spine to restore normal joint motion. Masasge, ice, heat, electrostimuation and other modalities can also be used to help reduce the pain and swelling associated with mid back pain.
Thoracic Outlet Syndrome
The thoracic outlet of the human body is an area in which a group of nerves from the neck travel from their exit points of the neck and continues under and through the first rib and collarbone. There are also blood vessels that travel through the same pathway. The nerves, blood vessels or both can be compressed along this pathway. There are also muscles along the neck called the scalene muscles and some chest muscles, which may also cause compression of the nerves.
Regardless of the type of compression of the nerves and vascular tissue, you will experience symptoms into your arm. Some of the signs may be numbness and tingling as well as a diminished sensation of touch. There can also be pain and weakness. If more of the blood vessels are compressed, you may notice an increase in swelling and discoloration of the arm. This condition can mimic other conditions such as Carpal Tunnel Syndrome and/ or nerve compression at the level of the cervical spine. There are a variety of ways to diagnose and differentiate Thoracic Outlet Syndrome from other conditions. Some of them may include an electromyographic test (EMG), which can help reveal areas of nerve entrapment along the pathway of the nerve. CT scan and x-ray can also help in the diagnosis.
If you are suffering from this, you may feel that your hands are going to sleep or have pins and needles in them. You also may begin to feel that your arm and hand are clumsy and weak. There may be a dull, deep ache in your arm and hand. Sometimes these symptoms will occur early in the morning and may on occasion awaken you from sleep. Prolonged sitting may also aggravate the condition, especially if these positions are accompanied by activities where you are looking down or using your hands and arms. Prolonged posture, which includes your head flexed forward, shoulders drooped or rolled forward and tightened chest muscles will also add to your symptoms.
Treatment options for this condition may include:
Chiropractic manipulation . Manipulation can help reduce the joint dysfunction that may be an added component of the pain. In the initial period your chiropractor will also use to use modalities, such as heat/ice or ultrasound, to help reduce muscle spasm and lessen referred arm pain.
Massage. Massage can treat active trigger points in the muscle that are producing pain and spasm that could be closing the thoracic outlet
Spinal Decompression or Cervical Traction. Traction on the head can help reduce pressure from the thoracic outlet. It does not work for everyone but is easy to do, and if effective the patient can use a home traction device.
Physical therapy / exercise rehab . Poor posture can decrease the thoracic out let so strengthening core muscles will improve posture opening up the thoracic outlet.
Activity modification. Some types of activities may tend to aggravated thoracic outlet syndrome. Decreasing or eliminating these activities sill help reduce the pain associated with thoracic outlet syndrome.
Surgical – on rare occasions surgical intervention is used to try and open up the outlet.
Coccydynia – a real pain in the tailbone
Coccydynia, or tailbone pain, is a fairly poorly understood condition that can cause persistent low back pain. It is felt as a localized pain at the very bottom of the spine (the coccyx) and will generally feel worse when sitting.
The condition is much more common in women than men. It is usually caused by local trauma (a fall) or giving birth. On rare occasions, an infection or tumor can also cause pain in the coccyx.
Local conservative treatments usually suffice to control or alleviate the pain. Rarely, surgical removal of the coccyx may be necessary if local conservative treatments are not effective in relieving the pain.
Causes of coccydynia
The coccyx is the very bottom portion of the spine. It represents a vestigial tail (hence the common term “tailbone”) and consists of four or more very small bones fused together. The coccyx articulates with the sacrum through a vestigial disc, and is also connected to the sacrum with ligaments
It is not clearly understood which portions of the anatomy can cause coccyx pain. Either the ligaments or the vestigial disc may be a cause of pain and, rarely, a primary bone tumor or soft tissue tumor can cause pain.
It is thought that the condition is more common in women because:
In women the coccyx is rotated and faces backward, which makes it more susceptible to trauma.
Women have a broader pelvis, which means that sitting places pressure not only on their ischial tuberosities (“butt bone”) but also on the coccyx. (Men tend to sit only on their ischial tuberosities without a lot of pressure applied to the coccyx).
Childbirth is a common cause of the condition.
The two most common causes of coccydynia are:
Local trauma. A fall on the tailbone can inflame the ligaments or injure the coccygeal attachment to the sacrum.
Childbirth. During delivery, the baby’s head rides over the top of the coccyx and can injure the same structures.
Conservative treatments for coccydynia
Patience is very important, since it often takes many weeks, or even months, for the pain to subside. Treatments for coccydynia:
If the pain is persistent or severe, additional conservative treatments may include:
Chiropracticmanipulations can provide relief.
Stretching the ligaments attached to the coccyx can be helpful.
Modalities with ultrasound, light/laser, electrostimulation can also be helpful.
A donut-shaped pillow to help take pressure off the coccyx when sitting.
A local injection of a numbing agent (lidocaine) and steroid (to decrease inflammation in the area) can provide some relief.
Facet Joint Osteoarthritis
Osteoarthritis (degenerative arthritis) can cause breakdown of cartilage between the facet joints. When the joints move, the lack of the cartilage causes pain as well as loss of motion and stiffness.
The facet joints are located in the back portion (posterior) of the spine. The joints combine with the disc space to create a three-joint complex at each vertebral level. The facet joint consists of two opposing bony surfaces with cartilage between them and a capsule around it that produces fluid. The combination of the cartilage and the fluid allows the joint to move with little friction. However, facet joint arthritis causes the cartilage to breakdown and the joint movement is associated with more friction. The patient loses motion and as they get stiffer they have more back pain.
Low back pain from osteoarthritis
Typically, the low back pain is most pronounced first thing in the morning. Throughout the day, normal movement causes fluid to build up in the joint and it becomes better lubricated, which decreases the pain. Later in the day the pain typically becomes worse again as more stress is applied across the joint.
Conservative treatments for osteoarthritis
Conservative treatments that concentrate on maintaining motion in the back are most effective for relieving the pain.
Chiropractic manipulation : manipulations of the involved joints to increase range of motion.
Exercise Rehab: Stretching exercises for the hamstring muscles, hip joints, and the back can usually serve to prevent the pain from getting worse.
Aqua Aerobics – Water therapy can be also be helpful since the joints are unweighted in the water and do not generate as much pain when being moved.
Medications: Acetaminophen is an effective and relatively safe non-prescription medication to help alleviate the pain, and some patients find NSAID’s (including Cox-2 inhibitors) to be helpful. Ask our medical for advice on any medications and their side effects.
Failed Back Surgery Syndrome
Failed back surgery syndrome: What it is and how to avoid it
Failed back surgery introduction
Failed back surgery syndrome describe the condition of patients who have not had a successful result with back surgery or spine surgery.
There are many reasons that a surgery may or may not work, and even with the best surgeon and for the best indications; spine surgery is no more than 95% predictive of a successful result.
Spine surgery is only basically able to accomplish two things:
Decompressing a nerve root that is pinched, or
Stabilizing a painful joint
Unfortunately, back surgery or spine surgery cannot literally cut out a patient’s pain. It is only able to change anatomy, and an anatomical lesion (injury) that is a probable cause of back pain.
By far the number one reason back surgery is not effective is because the lesion that was operated on is not in fact the cause of the patient’s pain.
Some types of back surgery are far more predictable in terms of alleviating a patient’s symptoms than others. For instance,
A discectomy (or microdiscectomy) for a lumbar disc herniation that is causing leg pain is a very predictable operation. However, a discectomy for a lumbar disc herniation that is causing lower back pain is far less likely to be successful.
A spine fusion for spinal instability (e.g. spondylolisthesis) is a relatively predictable operation. However, a spine fusion for multi-level lumbar degenerative disc disease is far less likely to be successful in reducing a patient’s pain.
In addition to the above-mentioned cause of failed back surgery syndrome, there are several other potential causes of a failed surgery, or continued pain after surgery:
Fusion surgery considerations (such as failure to fuse and/or implant failure, or a transfer lesion to another level after a spine fusion, when the next level degenerates and becomes a pain generator)
Lumbar decompression back surgery considerations (such as recurrent stenosis or disc herniation, inadequate decompression of a nerve root, preoperative nerve damage that does not heal after a decompressive surgery, or nerve damage that occurs during the surgery)
Scar tissue considerations (scarring tissue can wrap itself around the nerve becoming a constant source of pain)
Therefore, the best way to avoid a spine surgery that leads to an unsuccessful result is to stick to operations that have a high degree of success and to make sure that an anatomic lesion that is amenable to surgical correction is identified preoperatively.
Research indicates that chiropractic manipulation combined with specific strength and stabilizing rehabilitation exercises have a higher chance of easing and correcting your cause of pain than medication or physical therapy alone. Holmes Spine & Sport also utilizes an active spinal decompression table to release nerve pressure and help heal herniated disc and sciatica pain.
Chiropractic and other conservative care treatments can still be effective even when surgery has failed to relieve the pain . Holmes Spine & Sport Chiropractic provides a number of conservative treatments which makes it easier to get the care you need. We also work with your family physician and orthopedic surgeon.
Lumbar Degenerative Disc Disease
Lumbar degenerative disc disease
Degenerative disc disease refers to a syndrome in which a compromised disc causes low back pain. Lumbar degenerative disc disease usually starts with a torsional (twisting) injury to the lower back, such as when a person rotates to put something on a shelf or swing a golf club. However, the pain is also frequently caused by simple wear and tear on the spine.
Despite its rather dramatic label, degenerative disc disease is fairly common, and it is estimated that at least 30% of people aged 30-50 years old will have some degree of disc space degeneration, although not all will have pain or ever receive a formal diagnosis. In fact, after a patient reaches 60, some level of disc degeneration is deemed to be a normal finding, not the exception.
Lumbar degenerative disc disease pain and symptoms
Most patients with lumbar degenerative disc disease will experience low-grade continuous but tolerable pain that will occasionally flare (intensify) for a few days or more. Pain symptoms can vary, but generally are:
Centered on the lower back, although it can radiate to the hips and legs
Frequently worse when sitting, when the discs experience a heavier load than when patients are standing, walking or even laying down
Exacerbated by certain movements, particularly bending, twisting or lifting
The low back pain associated with lumbar degenerative disc disease is usually generated from one or both of two sources:
Inflammation, as the proteins in the disc space irritate the surrounding nerves, and/or
Abnormal micro-motion instability, when the outer rings of the disc – the annulus fibrous – are worn down and cannot absorb stress on the spine effectively, resulting in movement along the vertebral segment
Excessive micro-motion, combined with the inflammatory proteins, can produce ongoing low back pain
Fortunately, over time the pain from lumbar degenerative disc disease usually decreases, rather than becoming progressively worse. This is because a fully degenerated disc no longer has any inflammatory proteins (that can cause pain) and usually collapses into a stable position, eliminating the micro-motion that generates the pain.
Lumbar degenerative disc disease diagnosis
Following a review of the patient’s history and a physical examination, a formal diagnosis of lumbar degenerative disc disease can be confirmed with x-rays, ct scan, or magnetic resonance imaging (MRI). Findings that are closely linked to a painful disc include disc space collapse of greater than 50% and cartilaginous endplate erosion.
Lumber degenerative disc disease treatment
For most people, degenerative disc disease can be successfully treated with conservative (meaning non-surgical) care consisting of exercise, chiropractic, massage and ice and heat applications. Medication can also control inflammation and pain, however the effects that NSAIDS have on stomach linings and kidneys should make a person think twice for relying on medication as a long term treatment of degenerative disc disease. Surgery is only considered when patients have not achieved relief from conservative care and/or are significantly constrained in performing everyday activities.
Non-surgical treatment for degenerative disc disease
Chiropractic manipulation can relieve low back pain by taking pressure off sensitive nerves or tissue, increasing range of motion, restoring blood flow, reducing muscle tension, and, like more active exercise, promoting the release of endorphins within the body to act as natural painkillers
Applying heat to stiff muscles or joints to increase flexibility and range of motion, or using ice packs to cool down sore muscles or numb the area where painful flares are concentrated.
Medications such as non-steroidal anti-inflammatories may be used to manage intense pain episodes on a short-term basis, and some patients may benefit from an epidural steroid injection. Not all medications are right for all patients, and patients will need to discuss side effects and possible factors that would preclude taking them with their physician.
An exercise program is essential to relieving the pain of lumbar degenerative disc disease and should have several components, including:
Hamstring stretching, since tightness in these muscles can increase the stress on the back and the pain caused by a degenerative disc
A strengthening exercise program, such as Dynamic Lumbar Stabilization exercises, where patients are taught to find their ‘natural spine’, the position in which they feel most comfortable, and to maintain that position
Low-impact aerobic conditioning (such as walking, swimming, biking) to ensure adequate flow of nutrients and blood to spine structures, and relieve pressure on the discs
Traction Decompression Therapy and relieve pressure on sensitive nerve structures
At Holmes Spine & Sport Chiropractic we provide a number of conservative treatments under one roof to treat your lumbar disc degeneration. We also work with your family physician or orthopedic surgeon to assist in getting you any medications or consultations you may need.
Lumbar Herniated Disc
A common cause of low back and leg pain is a ruptured or herniated disc. Symptoms may include dull or sharp pain, muscle spasm or cramping, sciatica, and leg weakness or loss of leg function. Sneezing, coughing, or bending usually intensifies the pain. Rarely bowel or bladder control is lost, and if this occurs, seek medical attention at once.
Sciatica is a symptom frequently associated with a lumbar herniated disc. Pressure on one or several nerves that contribute to the sciatic nerve can cause pain, burning, tingling, and numbness that extends from the buttock into the leg and sometimes into the foot. Usually one side (left or right) is affected.
Anatomy – Normal Lumbar Disc
In between each of the five lumbar vertebrae (bones) is a disc, a tough fibrous shock-absorbing pad. Endplates line the ends of each vertebra and help hold individual discs in place. Each disc contains a tire-like outer band (called the annulus fibrosus) that encases a gel-like substance (called the nucleus pulposus).
Nerve roots exit the spinal canal through small passageways between the vertebrae and discs. Pain and other symptoms can develop when the damaged disc pushes into the spinal canal or nerve roots.
How a herniated disc causes pain
As a disc degenerates, it can herniate (the inner core extrudes) back into the spinal canal, which is known as a disc herniation (or a herniated disc). The weak spot in a disc is directly under the nerve root, and a herniated disc in this area puts direct pressure on the nerve, which in turn can cause pain to radiate all the way down the patient’s leg to the foot
Approximately 90% of disc herniations will occur at L4- L5 (lumbar segments 4 and 5) or L5- S1 (lumbar segment 5 and sacral segment1), which causes pain in the L5 nerve or S1 nerve, respectively.
L5 nerve impingement from a herniated disc can cause weakness in extension of the big toe and potentially in the ankle (foot drop). Numbness and pain can be felt on top of the foot, and the pain may also radiate into the rear.
S1 nerve impingement from a herniated disc may cause loss of the ankle reflex and/or weakness in ankle push off (e.g. patients cannot do toe rises). Numbness and pain can radiate down to the sole or outside of the foot (
Progression of disc herniation
Disc Degeneration: chemical changes associated with aging causes discs to weaken, but without a herniation.
Prolapse: the form or position of the disc changes with some slight impingement into the spinal canal. Also called a bulge or protrusion.
Extrusion: the gel-like nucleus pulposus breaks through the tire-like wall (annulus fibrosus) but remains within the disc.
Sequestration or Sequestered Disc: the nucleus pulposus breaks through the annulus fibrosus and lies outside the disc in the spinal canal (HNP).
Conservative treatment for a lumbar herniated disc
Conservative treatment options for a lumbar herniated disc
There are a number of non-surgical treatment options that can help alleviate the pain and hel heal a lumbar herniated disk:
Chiropractic manipulation. Gentle manipulation can help reduce the joint dysfunction and disc pressure. In the initial treatment period your chiropractor may also use modalities, such as heat/ice or ultrasound, to help reduce muscle spasm and lessen referred leg pain.
Massage. Massage can treat active trigger points and associated muscle tightness and spasm related to the nerve compression.
Spinal Decompression or Lumbar Traction. Traction/ decompression of the lumbar spine can help reduce pressure over the nerve root. It does not work for everyone but for those that get relief it can be an effective way to treat lumbar disc herniations.
Physical therapy / exercise rehab. Mckenzie exercises can be used to help reduce the pain in the leg. As the disc and nerve heal, more intense exercises can be added to stabilize the disc and joint complex.
Activity modification. Some types of activities may tend to exacerbate the herniated disc pain and it is reasonable to avoid these activities to keep from irritating the nerve root. Such activities may include heavy lifting, activities that can cause increased vibration and compression to the lumbar spine (boating, snowmobile riding, running, etc.).
Bracing. In some instances a lumbar brace/support belt may be recommended to help provide some rest for the lumbar spine.
Medications. In addition to the anti-inflammatory medication, narcotic agents (pain killers) might be used on a temporary basis to help reduce the pain and discomfort from a lumbar herniated disc. Also, muscle relaxants or certain anti-depressants may help reduce the nerve-type pain (neuropathic pain) and help restore normal sleep patterns. For patients with severe pain from a herniated disc, oral steroids (such as Predisone or a Medrol Dose Pak) may give even better pain relief. However, these medications can only be used for a short period of time (one week).
Injections. Epidural steroid injections or selective nerve root blocks can be helpful to reduce inflammation in cases of severe pain from a lumbar herniated disc, and can be very effective if accompanied by a comprehensive rehabilitation program that may involve a number of the above conservative treatments.
Spine surgery for a lumbar herniated disc
Most episodes of leg pain due to a lumbar herniated disc will resolve over a period of weeks to months. However, if the pain and disability is not improving or is worsening spine surgery may be a reasonable option.
Summary of lumbar herniated disc treatment options
Lumbar herniated disc typically respond well to conservative treatments. For the few cases that don’t respond well surgery may be your only option
At Holmes Spine & Sport Chiropractic we provide a number of conservative treatments under one roof to treat your lumbar disc herniation. We also work with your family physician or orthopedic surgeon to assist in getting you any medications or consultations you may need.
Muscle Strain and Low Back Pain
The majority of episodes of acute lower back pain are caused by a muscular strain (such as from lifting a heavy object, a sudden movement or a fall). Even though this doesn’t sound like a serious injury, the low back pain can be very severe and last for several hours, several days or even a couple of weeks or months.
When the muscles in the back are strained or torn, the area around the muscles can become inflamed. With inflammation the muscles in the back can spasm and cause both severe lower back pain and difficulty moving.
Healing from acute low back pain
Fortunately, muscle strains usually heal with time (a couple of days or weeks) because muscles in the low back have a good blood supply to bring the necessary nutrients and proteins for healing to take place.
However, an episode of low back pain that lasts for more than one – two weeks can lead to muscle weakness (since using the muscles hurts, the tendency is to avoid using them). This process leads to disuse atrophy (muscle wasting), and subsequent weakening, which in turn causes more low back pain because the muscles are less able to help hold up the spine. This also causes mechanical joint dysfunctions in the spine that can be corrected with chiropractic care.
Exercise helps prevent acute low back pain
As a general rule, people who are active and well-conditioned are much less likely to suffer from low back pain due to muscle strain, as regular exercise stretches the muscles so they are less likely to strain, tear or spasm.
There are three types of muscles that support the spine:
Extensors (back muscles and gluteal muscles)
Flexors (abdominal muscles and iliopsoas muscles)
Obliques or Rotators (side muscles)
While some of these muscles are used in everyday life, most do not get adequate exercise from daily activities and tend to weaken with age unless they are specifically exercised. A complete exercise program for the low back should consist of a combination of stretching, strengthening, and aerobic conditioning.
Common conditions that cause lower back pain
For patients with low back pain that lasts longer than two weeks to three months, or with predominantly leg pain, a more specific and definable problem is often the source of pain. Several types of low back and leg pain tend to be more common in either younger or older adults.
Common types of low back pain for young adults (< 60 years old) Leg pain and possible numbness Pain that radiates through the buttocks, as well as pain and possibly numbness that radiates down to the foot, is frequently caused by a disc herniation in the lumbar (lower) spine. This type of pain is usually worse after a long period of standing or sitting. * See also Lumbar disc herniation Mechanical low back pain Low back pain in young adults that is caused by movement (such as bending forward, running) is commonly caused by a syndrome called degenerative disc disease. This condition can result from a twisting injury that weakens the disc. The low back pain symptoms of degenerative disc disease can become chronic and may tend to fluctuate and at times become significantly worse. * See also Degenerative disc disease Low back pain (and possibly leg pain) that worsens when standing or walking Sometimes a vertebral body in the low back slips forward, causing stress on the disc, which in turn may cause low back pain and may sometimes cause leg pain. These painful symptoms are sometimes caused by a stress fracture that occurs at a young age. * See also spondylolisthesis Common types of low back pain for older adults (>60 years old)
Low back pain that is worse in the morning and in the evening, and stiffness
Low back pain that is most pronounced first thing in the morning and later in the day is often caused by facet joint osteoarthritis (degenerative arthritis), a condition that involves breakdown of the cartilage between the facet joints in the back. The pain and stiffness is a result of the lack of cartilage between the joints.
* See also Facet joint osteoarthritis
Pain down the legs when walking and standing upright
Leg pain that occurs when walking, and increases with more walking, can be caused by conditions such as lumbar spinal stenosis or degenerative spondylolisthesis. Both conditions place pressure on the nerves at the point where they exit the spine. Standing upright, such as in normal walking, increases pressure on the nerve and results in leg pain.
* See also Lumbar spinal stenosis and Spondylolisthesis
Piriformis syndrome — another irritation to the sciatic nerve
Piriformis syndrome and sciatica pain
Piriformis syndrome is a condition in which the piriformis muscle irritates the sciatic nerve and causes pain in the rear and may cause pain along the back of the leg and into the foot (similar to sciatica pain). Piriformis syndrome is most common among women, and is thought to be common among active individuals (such as runners and walkers).
While there is some controversy in the medical community, many health professionals believe that an accurate diagnosis and comprehensive management approach are critical to alleviate the sciatica type of pain caused by piriformis syndrome.
What is the piriformis muscle?
The piriformis muscle is a small muscle located deep in the rear (deep to the gluteus maximus).
The piriformis muscle:
Starts at the lower spine and connects to the upper surface of each femur (thighbone).
Functions to assist in rotating the hip.
Runs horizontally, with the sciatic nerve running vertically directly beneath it.
Piriformis syndrome can develop when the piriformis muscle becomes tight or spasms and places pressure on the sciatic nerve that runs beneath it. The pressure on the sciatic nerve can cause low back pain and/or pain that radiates to the rear and down the leg (similar to sciatica pain). From a technical standpoint, piriformis syndrome does not cause true sciatica (as sciatica is usually defined as a radiculopathy, or compression of a nerve root as it exits the spine). However, just like sciatica, piriformis syndrome can cause pain, numbness and tingling along the sciatic nerve, which runs down the back of the leg and into the foot.
Diagnosis of piriformis syndrome
There is no simple diagnostic test for piriformis syndrome causing irritation of the sciatic nerve. The condition is primarily diagnosed on the basis of the patient’s symptoms and on a physical exam.
Symptoms of piriformis syndrome
Most commonly, patients describe acute tenderness in the rear and sciatica-like pain down the back of the leg. Typical symptoms of piriformis syndrome may include:
A dull ache in the mid-rear
Pain down the back of the leg (a radiculopathy or sciatica)
Pain when walking up stairs or inclines
Increased pain after prolonged sitting
Symptoms of piriformis syndrome often become worse after prolonged sitting, walking or running, and may feel better after lying down on the back.
Physical exam to diagnose piriformis syndrome
The physical exam will include examination of the hip and legs to see if movement causes increased low back pain or leg pain (sciatica pain). Typically, motion of the hip will recreate the pain.
X-rays and other spinal imaging studies cannot detect if the sciatic nerve is being irritated at the piriformis muscle. However, diagnostic tests (such as X-rays, MRI and nerve conduction tests) may be conducted to exclude other conditions that can cause similar symptoms to piriformis syndrome (such as a disc herniation).
Comprehensive management of piriformis syndrome and sciatica pain
Depending on the severity of the patient’s sciatica-type pain and other symptoms, a number of treatment options may be recommended by a health care professional. A comprehensive approach to managing pain along the sciatic nerve from piriformis syndrome may include a combination of:
Chiropractic manipulation of the lumbar and sacral joints can restore proper motion to the spine and create an inhibitory reflex to shut down a spasm of the piriformis.
Stretching exercise for piriformis syndrome
A number of stretching exercises for the piriformis, hamstrings and hip extensors may help decrease the painful symptoms along the sciatic nerve and return the patient’s range of motion.
Ice for piriformis syndrome
At the onset of pain, lie in a comfortable position on your stomach and place an ice pack on the painful area for approximately 15 minutes. Repeat as needed every 2 to 4 hours.
If specific activities are usually followed by increased pain, it may be a good idea to apply ice immediately following the activity.
Range of motion exercises
A physical therapist can develop a customized program of stretching and range of motion exercises to help stretch the muscle and decrease spasm.
Deep massage (manual release) by a physical therapist is thought to enhance healing by increasing blood flow to the area and decreasing muscle spasm.
Some people find it helpful to use either ice or heat or to alternate cold with heat.
Medications for sciatica pain
Since most episodes of pain include some type of inflammation, non-steroidal anti-inflammatory medications (NSAID’s) (such as ibuprofen or naproxen) may help decrease inflammation in the affected area.
Injections for sciatica pain and piriformis syndrome
For severe sciatica pain, a local anesthetic and corticosteroid may be injected in directly into the piriformis muscle to help decrease the spasm and help alleviate the sciatica pain. The purpose of an injection is usually to decrease acute pain to enable progress in physical therapy. For persistent piriformis spasm that is resistant to anesthetic/corticosteroid injections, an injection of botulinum toxin (a muscle weakening agent) may be useful.
Electrotherapy and ultrasound for piriformis syndrome
The application of electrical stimulation and ultrasound to the rear with can help to block pain and reduce muscle spasm related to piriformis syndrome.
Pregnancy Related Low Back Pain
As many as 80% of pregnant women will experience low back pain, especially in their third trimester of the pregnancy.
Typically, the pain will be in the sacroiliac joints, and is probably due to a combination of carrying extra weight and hormonal factors that act to widen the sacroiliac joints and increase the size of the birth canal.
How can chiropractic and massage add comfort during pregnancy?
Chiropractic and massage care in pregnancy is an essential ingredient to your prenatal care choices. A large percent of all pregnant women experience back discomfort/ pain during pregnancy. This is due to the rapid growth of the baby and interferences to your body’s normal structural adaptations to that growth.
Preexisting unnoticed imbalances in your spine and pelvis become overtaxed during these times. The added stresses lead to discomfort and difficulty while performing routine, daily activities. Chiropractic and massage care throughout pregnancy can relieve and even prevent the common discomforts experienced in pregnancy. Specific adjustments eliminate these stresses in your spine, restore balance to your pelvis and result in greater comfort and lifestyle improvements.
Comfort for your baby, too.
As your baby develops, your uterus enlarges to accommodate the rapid growth. So long as the pelvis is in a balanced state, the ligaments connected to the uterus maintain an equalized, supportive suspension for the uterus. If your pelvis is out of balance in any way, these ligaments become torqued and twisted, causing a condition known as constraint to your uterus. This constraint limits the space of the developing baby. Any compromised position for the baby throughout pregnancy will affect his or her optimal development. Conditions such as torticollis occur because a baby’s space was cramped in utero.
If the woman’s uterus is constrained as birth approaches, the baby is prevented from getting into the best possible position for birth. Even if the baby is in the desirable head down position, often times constraint to the uterus affects the baby’s head from moving into the ideal presentation for delivery. The head may be slightly tilted off to one side or even more traumatically, present in the posterior position. Any baby position even slightly off during birth will slow down labor, and add pain to both the mother and baby. Many women have been told that their babies were too big, or labor “just slowed down” when it was really the baby’s presentation interfering with the normal process and progression. Avoidable interventions are implemented during a natural process into an operative one.
Doctors of Chiropractic work specifically with your pelvis throughout pregnancy restoring a state of balance and creating an environment for an easier, safer delivery.
A chiropractor can offer specific analysis and adjustments for your special needs in pregnancy. You and your baby’s continued safety and comfort is a primary concern. This pregnancy, offer yourself the best! Include the many benefits chiropractic offers in your prenatal care choices. Give you and your baby the opportunity for a more comfortable pregnancy and a safer, easier birth!
Sacroiliac Joint Dysfunction
What is sacroiliac joint dysfunction?
Dysfunction in the sacroiliac joint is thought to cause low back and/or leg pain. The pain can be similar to pain caused by a lumbar disc herniation. This condition is generally more common in young and middle age women.
The anatomical source of sacroiliac joint pain
The sacroiliac joint lies next to the spine and connects the sacrum (the triangular bone at the bottom of the spine) with the pelvis (iliac crest). The joint:
Is small and very strong
Transmits all the forces of the upper body to the pelvis (hips) and legs
Acts as a shock-absorbing structure
Has limited motion
While it is not clear how the pain is caused, it is thought that an alteration in the normal joint motion may be the culprit that causes sacroiliac joint pain. This source of pain can be caused by either:
Too much movement — hypermobility or instability, or
Too little movement — hypomobility or fixation. The pain is typically felt on one side of the low back or buttocks, and can radiate down the leg. The pain usually remains above the knee, but at times pain can extend to the ankle or foot.
Accurate diagnosis of sacroiliac joint dysfunction
Accurately diagnosing sacroiliac joint dysfunction can be difficult. The symptoms mimic other common conditions, such as disc herniation and radiculopathy (pain along the sciatic nerve that radiates down the leg).
A diagnosis is usually arrived at through physical examination:
Physical examination to determine the source of pain
In physical examination, the doctor may try to determine if the sacroiliac joint is the cause of pain through movement of the joint. If the movement recreates the patient’s pain, and no other cause of pain has been found (such as a disc herniation on an MRI scan), the sacroiliac joint may be the cause of the pain.
There are several orthopedic provocative tests that can be used in attempt to reproduce the symptoms associated with sacroiliac joint dysfunction. As a rule, several positive tests that reproduce pain specifically located at the sacroiliac joint improves the probability of the diagnosis of sacroiliac joint dysfunction.
Treatment options for sacroiliac joint dysfunction
Treatment for sacroiliac joint dysfunction is usually conservative (non-surgical) and focuses on restoring normal motion in the joint. One of the most effective ways to do this is through the chiropractic manipulation of the sacroiliac joint. Injections, exercise and NSAIDS may also may be used to treat sacroiliac pain.
What you need to know about sciatica
Low back pain and/or leg pain that usually travels down the large sciatic nerve, from the lower back down the back of each leg, is generally referred to as sciatica and is fairly common. This pain can be caused when a nerve root in the lower spine that helps form the sciatic nerve is pinched or irritated.
Sciatica is usually caused by pressure on the sciatic nerve from a herniated disc (also referred to as a ruptured disc, pinched nerve, slipped disk, etc.) in the lumbar spine.
Sciatica occurs most frequently in people between 30 and 50 years of age. Often a particular event or injury does not cause sciatica, but rather it may develop as a result of general wear and tear on the structures of the lower spine. The vast majority of people who experience sciatica get better with time (usually a few weeks or months) and find pain relief and correction with non-surgical treatments.
Understanding sciatica pain
For some people, the pain from sciatica can be severe and debilitating. For others, the pain might be infrequent and irritating, but has the potential to get worse. Usually, sciatica only affects one side of the lower body, and the pain often radiates from the lower back all the way through the back of the thigh and down through the leg. Depending on where the sciatic nerve is affected, the pain may also radiate to the foot or toes.
One or more of the following sensations may occur as a result of sciatica:
Pain in the rear or leg that is worse when sitting
Burning or tingling down the leg
Weakness, numbness or difficulty moving the leg or foot
A constant pain on one side of the rear
A shooting pain that makes it difficult to stand up
Low back pain may be present along with the leg pain, but usually the low back pain is less severe than the leg pain
While sciatica can be very painful, it is rare that permanent nerve damage (tissue damage) will result. Most sciatica pain syndromes result from inflammation and will get better within two weeks to a few months. Also, because the spinal cord is not present in the lower (lumbar) spine, a herniated disc in this area of the anatomy does not present a danger of paralysis.
Symptoms that may constitute a medical emergency include progressive weakness in the leg or bladder/bowel incontinence. Patients with these symptoms may have cauda equina syndrome and should seek immediate medical attention.
Any condition that causes irritation or impingement on the sciatic nerve can cause the pain associated with sciatica. The most common cause is a lumbar herniated disc. Other common causes of sciatica include lumbar spinal stenosis, degenerative disc disease, or spondylolisthesis, sacro-iliac joint dsfunction and piriformis syndrome.
Sciatica symptoms and causes
Back problems and the sciatic nerve
The sciatic nerve is the largest nerve in the body and is composed of individual nerve roots that combine to form the “sciatic nerve”. It starts in the low back at lumbar segment 3 (L3). The sciatic nerve roots run through the bony canal in the spine, and at each level in the lower back a pair of nerve roots exits from the spine and then comes together to form the large sciatic nerve that runs all the way down the back of each leg. Portions of the sciatic nerve then branch out in each leg to innervate certain parts of the leg (e.g. the calf, the foot, the toes).
The nerve roots that originate in the lower back are named for the upper vertebral body that they run between (for example, the nerve that exits at L4-L5 in the spine is named L4). The nerve passing to the next level runs over a weak spot in the disc space, which is the reason discs tend to herniate (extrude) right under the sciatic nerve root and can cause sciatica.
The sciatica symptoms (e.g., low back pain, leg pain, numbness, tingling, weakness) are different depending on where the pressure on the nerve occurs. For example, a lumbar segment 5 (L5) nerve impingement can cause weakness in extension of the big toe and potentially in the ankle (foot drop)
Treatment of sciatica requires a diagnosis of the underlying cause of the sciatica pain.
Back problems that cause sciatica pain
Common low back problems and other spinal conditions that can cause sciatica – pain along the sciatic nerve – include:
Lumbar herniated disc. A herniated disc occurs when the soft inner core of the disc (nucleus pulposus) extrudes through the fibrous outer core (annulus) of the disc and the bulge places pressure on the contiguous nerve root as it exits the spine. In general, it is thought that a sudden twisting motion or injury can lead to an eventual disc herniation and sciatica. However, most discs weaken due to repetitive stress and the final result is a herniation. A herniated disc is sometimes referred to as a slipped disk, ruptured disk, bulging disc, protruding disc, or a pinched nerve.
* See also Lumbar disc herniation
Lumbar spinal stenosis. This condition commonly causes sciatica due to a narrowing of the spinal canal. It is more common in adults over age 60, and typically results from a combination of one or more of the following: enlarged facet joints, overgrowth of soft tissue and a bulging disc placing pressure on the nerve roots as they exit the spine.
* See also Lumbar spinal stenosis
Degenerative disc disease. While disc degeneration is a natural process that occurs with aging, in some cases one or more degenerated discs can also irritate a nerve root and cause sciatica. Degenerative disc disease is diagnosed when a weakened disc results in excessive micro-motion at the corresponding vertebral level and inflammatory proteins from inside the disc become exposed and irritate the area (including the nerve roots). The term “degenerative disc disease” is an unfortunate one as it is a process, not a disease.
* See also Degenerative disc disease
Spondylolisthesis. This condition is not that uncommon in adults (approximately 5% to 7% of adults are thought to have it), but it only rarely causes back pain or sciatica pain. Spondylolisthesis occurs when a small stress fracture (most often at the fifth segment) allows the L5 vertebral body to slip forward on the S1 vertebral body. Caused by a combination of disc space collapse, the fracture, and the vertebral body slipping forward, the L5 nerve can get pinched as it exits the spine.
* See also spondylolisthesis
Piriformis syndrome. The sciatic nerve can also get irritated as it runs under the piriformis muscle in the rear. If the piriformis muscle irritates or pinches a root that comprises the sciatic nerve, it can cause sciatica-type pain. This is not a true radiculopathy, but the pain can feel the same as sciatica caused by a nerve irritation.
* See also Piriformis syndrome—another irritation to the sciatic nerve
Sacroiliac joint dysfunction. Irritation of the sacroiliac joint at the bottom of the spine can also irritate the L5 nerve, which lies on top of it, and cause sciatica-type pain. This is not a true radiculopathy, but the pain can feel the same as sciatica caused by a nerve irritation.
* See also What is sacroiliac joint dysfunction?
The good news for patients is that sciatica usually will get better over time, and the healing process usually only takes a few days or weeks. Overall, the vast majority of episodes of sciatica pain heal within a six to twelve week time span. However, occasional flare-ups of sciatic nerve pain may be an indication of a condition that should be managed so that it does not get worse over time. For most, chiropractic and regular exercise will go a long way to remedying the situation.
Sciatica medical treatments
During an episode of sciatica, there are a number of conservative care (meaning non-surgical) options available to help alleviate the sciatic pain and discomfort.
Chiropractic spinal adjustments and manual manipulation are focused on providing better spinal column alignment, which in turn should help to address a number of underlying conditions that can cause sciatic nerve pain. Chiropractic manipulation addresses the cause of the sciatic pain and can provide lasting relief.
Heat/ice for sciatica
For acute sciatica pain, heat and/or ice packs are most readily available and can help alleviate the pain, especially in the acute phase. Usually ice or heat is applied for approximately 20 minutes, and repeated every two hours. Most people use ice first, but some people find more relief with heat. The two may be alternated to help with sciatica pain relief.
Certain forms of massage therapy have been shown to have a number of benefits for back pain, including increased blood circulation, muscle relaxation, and release of endorphins (the body’s natural pain relievers).
Spinal Decompression or Lumbar Traction
Traction on the lumbar spine can help reduce pressure over the nerve root. It does not work for everyone but for those that get relief it can be an effective way to treat sciatica.
Medications for sciatica
Over-the-counter or prescription medications may also be helpful in relieving sciatica. Non-steroidal anti-inflammatory drugs (such as ibuprofen, naproxen, or COX-2 inhibitors), or oral steroids can be helpful in reducing the inflammation and pain associated with sciatica. Please talk to your medical doctor regarding treatment with drugs and their associated side effects
Epidural steroid injections for sciatica
If the sciatica pain is severe, an epidural steroid injection can be performed to reduce the inflammation. An epidural injection is different from oral medications because it injects steroids directly to the painful area around the sciatic nerve to help decrease the inflammation that may be causing the pain. While the effects tend to be temporary (providing pain relief for as little as one week up to a year), and it does not work for everyone, an epidural steroid injection can be effective in providing relief from an acute episode of sciatic pain. Importantly, it can provide sufficient relief to allow a patient to progress with a conditioning and exercise program.
Physical therapy and exercise
When the sciatica pain is at its worst, patients may need to rest for a day or two, but resting for longer periods of time is usually not advisable. In fact, inactivity will usually make the sciatic pain worse. This is because regular movement and exercise is necessary to nourish the various structures in the low back and encourage the strength needed to support the low back.
Many sciatica exercises focus on strengthening the abdominal and back muscles in order to give more support for the back. Stretching exercises for sciatica target muscles that cause pain when they are tight and inflexible. When patients engage in a regular program of gentle strengthening and stretching exercises, they can recover more quickly from a flare up of sciatica and can help to prevent future episodes of pain.
Low impact aerobic exercise, such as walking or swimming (or pool therapy) is also usually a component of recovery, as aerobic activity encourages the exchange of fluids and nutrients to help create a better healing environment. Aerobic conditioning also has the added benefit of releasing endorphins, the body’s natural pain killers, which is a natural way to alleviate sciatic pain.
Lumbar laminectomy (open decompression) for sciatica
Lumbar spinal stenosis often causes sciatica pain that waxes and wanes over many years. Surgery may be offered as an option if the patient’s activity tolerance falls to an unacceptable level. Again, surgery is elective and need only be considered for those patients who have not gotten relief from the sciatica after pursuing non-surgical treatments. The patient’s general health may also be a consideration.
After a lumbar laminectomy (open decompression), approximately 70% to 80% of patients typically experience relief from their sciatic nerve pain.
It is important to note that the decision whether or not to pursue surgical or non-surgical remedies for sciatica is almost always the patient’s decision. There are many considerations for the patient to take into account when deciding whether or not to have surgery.
At Holmes Spine & Sport Chiropractic we provide a number of conservative treatments to treat your sciatic pain. We also work with your family physician or orthopedic surgeon to assist in getting you any medications you may need.
What Is Spondylolisthesis
Spondylolisthesis occurs when one vertebra slips forward in relation to an adjacent vertebra, usually in the lumbar spine. The symptoms that accompany a spondylolisthesis include pain in the low back, thighs, and/or legs, muscle spasms, weakness, and/or tight hamstring muscles. Some people are symptom free and find the disorder exists when revealed on an x-ray. In advanced cases, the patient may appear swayback with a protruding abdomen, exhibit a shortened torso, and present with a waddling gait.
Spondylolisthesis can be congenital (present at birth) or develop during childhood or later in life. The disorder may result from the physical stresses to the spine from carrying heavy things, weightlifting, football, gymnastics, trauma, and general wear and tear. As the vertebral components degenerate the spine’s integrity is compromised.
Another type of spondylolisthesis is degenerative spondylolisthesis, occurring usually after age 50. This may create a narrowing of the spinal canal (spinal stenosis). This condition is frequently treated by surgery.
Diagnosis of Spondylolisthesis
A routine lateral (side) radiograph taken while standing confirms a diagnosis of a spondylolisthesis . The x-ray will show the translation (slip) of one vertebra over the adjacent level, usually the one below.
Using the lateral (side) x-ray, the slip is graded according to its degree of severity. The Myerding grading system measures the percentage of vertebral slip forward over the body beneath. The grades are as follows:
Grade 1: 25%
Grade 2: 25% to 49%
Grade 3: 50% to 74%
Grade 4: 75% to 99%
Grade 5: 100%*
*Complete vertebral slippage, known as spondyloptosis.
If the spondylolisthesis is non-progressive, no treatment except observation is required. Symptoms often abate once precipitating activities cease. Conservative treatment includes 2 or 3 days of rest, restriction of activities causing stress to the lumbar spine (e.g. heavy lifting, stooping), chiropractic, physical therapy, anti-inflammatory and pain reducing medication, and/or a corset or brace.
Surgical intervention is considered when neurologic involvement exists or conservative treatment has failed to provide relief from long-term back pain and other symptoms associated with spondylolisthesis
A spine surgeon decides which surgical procedure and approach (anterior/posterior, front or back) is best for the patient. His decisions are based on the patient’s medical history, symptoms, radiographic findings, as well as the grade and angle of the vertebral slip. A variety of surgical treatment options are utilized. You should discuss what is best for your condition with your spine surgeon.
Avoid heavy lifting, stooping, or certain sports such as football or high impact exercise (i.e. running, aerobics). Any doubts concerning vocational and recreational restrictions should be discussed with your physician. They will be able to suggest safe alternatives to help reduce the risk of further back problems.
Keep your weight close to ideal, continue to follow the exercise program designed by your chiropractor or physical therapist at home, learn how to pick up things off the floor correctly, as well as other ‘safe’ movements.
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