Please often discount how significant of an injury whiplash really can be. I wanted to take a moment to shine a different light on this important subject.
Whiplash, as previously discussed, occurs quicker than the speed at which we can voluntarily contract our muscles in attempt to guard ourselves against injury. Hence, it is nearly impossible to properly brace in anticipation of an impending collision. When muscles, ligament, and joint capsules become injured, there is pain, and as a result, reflex muscle spasm occurs as the body attempts to “splint” the area to protect it. This sometimes sets up a vicious cycle which can make the pain last longer, hurt more intensely and / or hurt more frequently. Because of pain, as well as direct muscle injury that sometimes occurs in whiplash associated disorders (WAD), the natural tendency is to stop doing many activities and guard against motion both because of pain and the fear of it hurting worse. In both cases, the result is the same: muscle atrophy or shrinkage and muscle weakness due to not using the muscle.
There are other reasons that muscles become weak. When an injury occurs, a herniated or “ruptured” disk can injure the spinal nerves exiting the spine. The disk is like a jelly donut where the center is liquid-like surrounded by a thick ring of fibrocartilage and functions as a “shock-absorber” as it sits between 2 vertebral bodies
Think of the spinal nerves like electrical wires that connect a fuse box to a house. The fuse box is the spinal cord and each wire represents the spinal nerves going to different parts of the house (body). In the cervical spine or neck, each wire goes to different parts like the head, shoulder, arm, and hand and innervates specific areas. Patients who have a pinched nerve from a whiplash injury describe their symptoms as numbness, tingling, pain and/or muscle weakness in a specific distribution or area.
There are 8 pairs of nerves in the neck that travel to different parts of the head (C1-3), the shoulders (C4, 5), and the arm (C6-T2). Let’s say a patient has numbness and tingling down the arm to the 4th & 5th fingers and the pinky side of the hand. That immediately tells us as chiropractors that the C8 nerve is injured (pinched) because that’s the pain pattern of the C8 nerve. Certain muscles are controlled by C8 that we can test in our office to determine if they are weak (abnormal) or strong (normal).
We grade the weakness between 0-5 (5=normal). The chiropractic treatment is aimed at un-pinching the nerve which results in a return of normal nerve function or no numbness/tingling and a strong C8 muscle (finger flexion strength). To accomplish this, we may use a combination of treatments such as spinal adjustments, spinal decompression, mobilization, traction, exercises, and/or modalities (electric stim, light therapy, ultrasound or others).
That’s it for today.
Core training is a no-longer-new catchphrase on the fitness landscape. The concept of core fitness, by now, has been promoted by every Pilates school, yoga center, and chain of fitness clubs around the world. Many doctors, including chiropractors, physiatrists, orthopedists, and even cardiologists, emphasize the importance of core training with their patients. Practically every physical therapist and personal trainer has learned a variety of core exercises to use with their clients. Core fitness has become an advertising buzzword, helping to sell all kinds of health-related products. The overall result is raised awareness of the importance of core strength and the opportunity to engage in a critically important form of healthy exercise.1,2,3
What exactly is the “core” and what are you training when you train it? Your core muscles are your four abdominal muscle groups – the transversus abdominis, internal obliques, external obliques, and rectus abdominis. Back muscles, too, are included in the core group – specifically the erector spinae, longissimus thoracis, and multifidus. The importance of the core muscles is their ability to provide a “center” or focus for the physical work your body is doing. If your core is not fit other muscles will have to take over, leading to the likelihood of strains, sprains, and other injuries.
Who even knew we had a core? Plenty of people did, long ago, but in those days no one talked about a “core”. For many decades football coaches, ballet instructors, and gymnastics coaches trained their athletes in vigorous and strenuous techniques that all focused on core strength. High school gym teachers knew about the core. Remember squat thrusts, jumping jacks, and push-ups? All those ancient exercises (that we used to groan and moan about) train deep core muscles. We were doing core fitness before there was “core fitness”.
Why do we need core fitness today? More and more our work involves sitting down. We stare at computer screens for eight hours a day. Instead of doing physical work such as farming or building, we type on a keyboard and talk on a cell phone. The long-term result is that muscles, tendons, and ligaments lost their integrity. Tight neck muscles, tight lower back muscles, and weak abdominal muscles are the result, and these issues lead to more serious problems such as chronic headaches, cardiovascular stress, impaired digestion, and depression. We need fitness activities that start building us back up again, and the right place to start is at the center – by engaging in core fitness.
The best thing about core fitness is that you don’t need any equipment. You could get a mat and a physioball, but those items are optional. Take a yoga class. Take a Pilates class. Learn a few core exercises and begin to do them several times a week. You’ll soon begin to notice that you feel better, in general. You have more energy. You’re sleeping better. Your mood is improving. All due to a few squats, a few planks, and a few push-ups. That’s a pretty good deal.
That’s it for now…
Dr. Troy Don, DC QME
1Kennedy DJ, Noh MY: The role of core stabilization in lumbosacral radicuopathy. Phys Med Rehabil Clin North Am 22(1):91-103, 2011
2Behm DG, et al: The use of instability to train the core musculature. Appl Physiol Nutr Metab 35(1):91-108, 2010
3Dunleavy K: Pilates fitness continuum: post-rehabilitation and prevention Pilates fitness programs. Rehab Manag 23(9):12-15, 2010
Patient education is a very important aspect of caring for our patients. In fact, it can be one of the most important aspects of care. For example, when patients present with a brand new injury and pain levels are off the map, it’s quite common for that acute suffering patient to inappropriately think that, “I’m going to die… this hurts so much!” Hence, one of the very first things we do as chiropractors is to determine what structures are generating the pain so we can tell you!
Once you have an understanding of where the pain is coming from and why it hurts so bad, then you can be reassured that it’s not life threatening or dangerous. Also, at this acute point of time, the patient often unknowingly puts heat on the back, often for hours. This is the WORST thing you can do as the area is already swollen and putting heat on a swollen area draws more blood and fluids into the area. It’s literally like throwing gas on a fire. So, receiving proper information from us such as, put ice on the area for 15-20 minutes on and off several times in a row to “PUMP” the swelling out of the area will make complete sense.
Also, did you know that 2/3rds of our body’s weight is above the waist? That means, when a 150# person bends over, they are “lifting” 100#! That’s one of several reasons why bending over can be so dangerous. To “fix” that, squat by bending the knees keeping the back straight and keep objects that you might be lifting close to your body as that weight literally weighs 10x more when your arms are straight and you’re lifting. When you can’t squat and have to bend over, bend the knees, arch your back (literally “stick your butt out”), and bend over at your hip joints – DON’T use your back. You’ll need to practice that one a few times before it’s fully understood.
As your back pain improves, we will review these important self-help approaches and add new “tricks of the trade” like certain stretches, some strengthening and perhaps some balance exercises. Did you know that your thigh muscles shrink just by sleeping overnight? It’s true! When you wake up in the morning, your thigh muscles are smaller than when you went to bed. Well, this same muscle shrinkage (technically called “atrophy”) occurs in the lower back and hips, so strengthening exercises are REALLY IMPORTANT! Just think, if your muscles shrink overnight just from laying in bed, what about when you might have been told to use bed rest for several days or more? There potentially is a lot of muscle shrinkage and weakness that can occur in a relatively short amount of time and therefore, strengthening exercises also need to be taught in order to regain your strength so you can more safely do your activities.
Now what about back pain prevention? What methods to you think will help us NOT get low back pain? That’s right – managing weight! If your BMI (body mass index or, the ratio between your height and weight) is >25, you need to trim down a bit (or more). Go on line and SEARCH BMI, and pick one of many “BMI Calculators” to figure out your BMI. So, what do chiropractors know about weight loss? Did you know the chiropractic college curriculum includes more nutritional courses than most medical schools? We will help you find a way to lose weight – whether its calorie restriction, a special diet like no/low salt, gluten-free, or a diabetes-specific diet. Another prevention trick for the low back (actually, whole body!) is to STAY FIT! Make aerobic exercise and even a light weight lifting program part or your daily ritual. Other methods help too, so come in and let us guide you in this journey to better health!
Dr. Troy Don, DC QME
Low back pain can arise from many conditions, one of which is a mouthful: spondylolisthesis. The term was coined in 1854 from the Greek words, “spondylo” for vertebrae and “olisthesis” for slip. These “slips” most commonly occur in the low back, 90% at L5 and 9% at L4. According to www.spinehealth.com and others, the most common type of spondylolisthesis is called “isthmic spondylolisthesis,” which is a condition that includes a defect in the back part of the vertebra in an area called the pars interarticularis, which is the part of the vertebra that connects the front half (vertebral body) to the back half (the posterior arch). This can occur on one, or both sides, with or without a slip or shift forwards, which is then called spondylolysis. In “isthmic spondylolisthesis,” the incidence rate is about 5-7% of the general population favoring men over women 3:1. Debate continues as to whether this occurs as a result genetic predisposition verses environmental or acquired at some point early in life as noted by the increased incidence in populations such as Eskimos (30-50%), where they traditionally carry their young in papooses, vertically loading their lower spine at a very young age. However, isthmic spondylolisthesis can occur at anytime in life if a significant backward bending force occurs resulting in a fracture but reportedly, occurs most frequently between ages 6 and 16 years old.
Often, traumatic isthmic spondylolisthesis occurs during the adolescent years and in fact, is the most common cause of low back pain at this stage of life. Sports most commonly resulting in spondylolisthesis include gymnastics, football (lineman), weightlifting (from squats or dead lifts) and diving (from over arching the back). Excessive backward bending is the force that overloads the back of the vertebra resulting in the fracture sometimes referred to as a stress fracture, which is a fracture that occurs as a result of repetitive overloading over time, usually weeks to months.
If the spondylolisthesis lesions do not heal either by cartilage or by bone replacement, the front half of the vertebra can slip or slide forwards and become unstable. Fortunately, most of these heal and become stable and don’t progress. The diagnosis is a simple x-ray, but to determine the degree of stability, “stress x-rays” or x-rays taken at endpoints of bending over and backwards are needed. Sometimes, a bone scan is needed to determine if it’s a new injury verses an old isthmic spondylolisthesis.
Another very common type is called degenerative spondylolisthesis and occurs in 30% of Caucasian and 60% of African-American woman (3:1 women to men). This usually occurs at L4 and is more prevalent in aging females. It is sometimes referred to as “pseudospondylolisthesis” as it does not include defects in the posterior arch but rather, results from a degeneration of the disk and facet joints. As the disk space narrows, the vertebra slides forwards. The problem here is that the spinal canal, where the spinal cord travels, gets crimped or distorted by the forward sliding vertebra and causes compression of the spinal nerve root(s), resulting pain and/or numbness in one or both legs. The good news about spondylolisthesis is that non-surgical approaches, like spinal manipulation in particular, work well and chiropractic is a logical treatment approach!
Dr. Troy Don, DC QME
Low back pain can emanate from many anatomical locations (as well as a combination of locations), which always makes it interesting when a patient asks, “…doc, where in my back is my pain coming from?” In context of an office visit, we take an accurate history and perform our physical exam to try to reproduce symptoms to give us clues as to what tissue(s) may be the primary pain generators. In spite of our strong intent to be accurate, did you know, regardless of the doctor type, there is only about a 45% accuracy rate when making a low back pain diagnosis? This is partially because there are many tissues that can be damaged or injured that are innervated by the same nerve fibers and hence, clinically they look very similar to each other. In order to improve this rather sad statistic, in 1995 the Quebec Task Force published research reporting that accuracy could be improved to over 90% if we utilize a classification approach where low back conditions are divided into 1 of 3 broad categories:
- Red flags – These include dangerous conditions such as cancer, infection, fracture, cauda equina syndrome (which is a severe neurological condition where bowel and bladder function is impaired). These conditions generally require emergency care due to the life threatening and/or surgical potential.
- Mechanical back pain – These diagnoses include facet syndromes, ligament and joint capsule sprains, muscle strains, degenerative joint disease (also called osteoarthritis), and spondylolisthesis.
- Nerve Root compression – These conditions include pinching of the nerve roots, most frequently from herniated disks. This category can include spinal stenosis (SS) or, combinations of both, but if severe enough where the spinal cord is compromised (more commonly in the neck), SS might then be placed in the 1st of the 3 categories described above.
The most common category is mechanical back pain of which “facet syndrome” is the most common condition. This is the classic patient who over did it (“The Weekend Warrior”) and can hardly get out of bed the next day. These conditions can include tearing or stretching of the capsule surrounding the facet joint due to performing too many bending, lifting, or twisting related activities. The back pain is usually localized to the area of injury but can radiate down into the buttocks or back of the thigh and can be mild to very severe.
That’s it for now.
Dr. Troy Don, DC QME
After 6 months of seminars and travel I feel I am now able to get back to blogging. I’m excited to share with you some thought and ideas that I’ve had over the months… and I think you’ll find these interesting as well.
Today I’d like to share with you some interesting findings in some studies that have been done that pertain to movement and back pain.
I’m sure you’ve heard it before – “my back hurts… I just want to rest” or perhaps “oh boy my back has been a problem for so long that I’m afraid to do anything for fear that I’ll hurt my back.” Or maybe you’ve heard “my back hurts all the time now even though I don’t do anything!”
If you have had back pain you know what I’m talking about. If you have had severe pain, you know realize how easy it is to put limitations on yourself and on your activities.
This is the trap…
Your pain conditions you to be less active… so much so that you become de-conditioned or even worse yet, sedentary. That decrease in activity and movement leads to something called spinal wind-up. This spinal wind-up leads to a neurological self feeding spiral of more and more pain, EVEN THOUGH you are not active or moving.
In other words, if you don’t move your joints you are destine to have more and more pain!
How do we fix this?
Easy. Get moving!
Will this hurt? Maybe… BUT it will start the process for breaking the cycle of spinal windup.
Chiropractic is fantastic at getting the joints moving. The chiropractic adjustment floods the nervous system with positive nerve message to seize spinal windup. Exercise and movement is great at helping to fall into the trap.
If you are hurting “even though you’re not doing anything”, I strongly encourage you to seek chiropractic care. Then start some type of EASY movement program to help you get more years out of your life and more life out of your years.
That’s it for now…
Dr. Troy Don, DC QME
It’s been reported that educating the patient about their condition reduces unnecessary anxiety and fear, which in turn, allows a more swift resolution of their condition. The intensity of low back pain (LBP) can sometimes be so severe, the patient can hardly move without getting a sharp, knife-like pain that stops them in their tracks. When one experiences this kind of pain, it’s very easy to assume what’s causing this, “….must be lethal!” Or perhaps, “how can anything hurt this bad and not be cancer?” These types of thoughts can lead to unnecessary (and frankly, inappropriate) behavior including fear of activity (including work), anxiety, depression, and poor coping skills. In this regard, all LBP guidelines include the important recommendation of offering appropriate reassurance and advice through patient education as it is KEY to reducing this unnecessary fear and anxiety. This includes educating the patient as to what hurts them (anatomical tissue damage), why it hurts so badly (the inflammatory cycle), and what they can and should do to get out of the acute, painful stage as quickly as possible (“RICE” or, Rest, Ice, Compress, Elevate).
Education is related to experience. Stop and think about how a child manages pain. When they fall down and skin their knees, the intensity of their crying can be deafening! It’s obvious the child’s the reaction is exaggerated, as exemplified by that blood curdling scream. The reason for this heightened reaction is due to the lack of experience or, “knowledge” about this type of injury – they don’t realize the pain will dissipate with a few minutes and as a result, they over react. As we age, skinning our knees is more irritating mentally than it is painful – we look at it, after muttering a few words under our breath (which won’t be repeated here), and then we go about our daily routine, knowing fully well that it will hurt for a while and eventually get better. Studies have shown that people who have graduated from high school or college have a higher pain threshold than those who have not. This may be because, through learning about the body in science class, they understand the anatomy and physiology (structure and function) behind a cut on the skin. As a result, there is no overreaction, just a “reaction.”
So, when can this educational process start? The answer is simple – as soon as possible; and actually, before we become patients! A recent study published in the journal “SPINE,” found 8 year old school children were capable of out-performing a similar aged “control” group that were not educated on management and prevention of low back pain. Tests were administered initially, at 15 days and at 98 days after beginning the education process. They used a comic book as the method to educate the 266 member group of 8 year olds while a “control” group of 231 kids did not receive the comic book educational tool. Initially, the 2 groups scored similarly (about 73% correct answers for both groups). The comic book was given to the 266 kid group at day 8 and both groups were retested again at the 15 and 98 day time points. The results showed the group receiving the comic book education about LBP scored significantly higher at 15 days and retained the information at 3 months. Though no one will know if the educated kids will be less prone to develop chronic pain due to this gain of knowledge, the increased likelihood certainly exists.
The take home message is, use the internet and all other resources to learn as much as you can about your back condition. Of course you’re doing that already if you’re reading this online.
Troy Don, DC QME
Advanced Health Source
In my Rancho Cucamonga and Pasadena office, it is not uncommon for me to have a conversation with a patient regarding surgery and their desire to avoid it. I’ve been blessed to have used nonsurgical spinal decompression and chiropractic to achieve that goal with many patients. So, I figured today we would discuss in this blog Spinal Fusion surgery.
You may think it’s odd to discuss low back pain (LBP) from the perspective of spinal fusion because as chiropractors, we do not perform surgery and so, why discuss it? It is important that we discuss research such as this so we can make the informed treatment decisions with our patients after we’ve considered all the facts in each specific case. Now, there are certainly times when a surgical procedure for back and leg pain is necessary and appropriate for some patients, but the problem is, there are also some patients who have been told they need spinal surgery when, in fact, they may be better off NOT proceeding with surgery. So, the question is, what happens to those patients who elect not, vs. those who do choose to proceed with surgery?
That question was addressed in a study where a total of 1450 patients injured at work were followed over a 2-year time frame. There were a total of 725 patients who proceeded with the fusion surgery and the other 750 elected NOT to have the surgery. A fusion surgery can be described as when two or more vertebra are fused together, usually because there are neurological problems such as shooting leg pain, weakness and/or numbness in one or both legs. The conditions treated in this study included herniated disks, degeneration of the disk, and radiating leg pain. There were primarily 3 factors that were compared between the two groups, namely, 1) ability to return to work; 2) disability (the inability to work), and 3) opiate (narcotic) drug use. Other factors compared included the need for re-operations, complications, and death.
The results showed, in general, those who proceeded with surgery had significantly more problems compared to those who did not have surgery. For example, only 26% returned to work, compared to 67% returned to work. The total number of days off work were 1140 vs. 316 days, respectively. There were 17 vs. 11 deaths, respectively and, 27% of the surgical group required re-operations with a 36% complication rate. Also, there was a 41% increase in the use of narcotic medication with 76% continuing the use after surgery.
Again, there are times when surgery is absolutely the right choice. Those times include when there is a loss of bladder or bowel control, progressively worsening neurological symptoms in spite of non-surgical care, and of course, unstable fractures, cancer/tumor and infections, but that’s about it! In other words, if you don’t have one of the before mentioned conditions which do require surgery, don’t be too quick to jump at the chance of “getting it fixed” with surgery. As the study suggests, the post-surgical results favor those who elected NOT to have surgery. Also, when in doubt, don’t trust the opinion of only one surgeon – always get a 2nd or even 3rd opinion. It is also very important to consider your current level of function or, your ability to do your desired tasks and, unless there is a significant loss in that ability, consider additional time with non-surgical treatment. The non-surgical treatment you can expect to receive from chiropractic includes (but may not be limited to) spinal manipulation, spinal decompression, exercise training, physical therapy modalities (ice, heat, electrical stimulation, ultrasound, traction, etc.), dietary counseling, and job modification information.
Unfortunately too often patients elect to have surgery without all the answer to make an informed decision. I hope this helps you.
Dr. Troy Don, DC QME
“Were does the pain come from?” is probably the most commonly asked question we hear as chiropractors and frequently, the patient is not told the answer to this simple question. The problem is, the question is not so simple. This is because there are many structures in the low back that share a common nerve supply and hence, the pain arising from those structures is located in the same area of the back. For example, the back portion of the disk, the facet capsule and some of the deep muscles in the spine are all innervated by the same nerve and therefore hurt is a similar location. In all honesty, the only way to try to isolate the pain generator is to inject a local anesthetic to block the pain for a short while. This is like when you go to the dentist and they “numb” your tooth so you don’t feel the pain when they work on it. After a few hours, you start to feel some “life” coming back to your mouth and soon it regains its full feeling. Of course, no one would consider “numbing” the back just to figure out exactly where the pain is arising as really, it’s not that important. This is because the chiropractic treatment approach is similar regardless of the exact tissue that is involved. However, it DOES matter in cases where a nerve root is shooting pain down the leg caused by a herniated disk vs. a localized pain in the back that doesn’t radiate. Hence, we doctors of chiropractic will work hard to differentiate these two distinct types of conditions as the treatment is definitely different.
In 1995, the Quebec Task Force recognized the importance of this distinction and recommended all health care providers concentrate on differentiating the nerve root / herniated disk case from what is called “mechanical low back pain.” As noted in the model below, the arrow and pen point to the two most common structures that cause nerve root pain (the herniated disk) and mechanical low back pain (the facet joint).
The facet joint, when sprained / injured, hurts worse when bending backwards and feels good bending forwards. This is exactly the opposite for the herniated disk where bending backwards helps reduce pain and often reduces the shooting leg pain as well, while bending over even a little can create a sharp stabling pain in the back that may shoot down the leg. Of course, there are variations of this and, to make matters more complicated, BOTH the disk and the facet can generate pain at the same time, so it’s not always this cut and dry.
Troy Don, DC QME
Patients often ask me that why I am so concerned that they are stretching their back on a regular basis. I then explain to them that if the leg muscles are overly tight, that those muscles will cause the pelvis to be tilted in such a way that will negatively affect the back stability.
So here are some exercises that I recommend for keeping the back loose. I hope to get some more videos up so that I can simply show you the exercises. In any event… here are 5 great flexibility stretches.
Alternating Knee to Chest
Lie on your back with legs straight. Bring your right leg up placing your hands behind your thigh and pulling with your arms so that your bent knee comes toward your chest. Hold this for 10 seconds. Relax the pull for 5 seconds, pull again for 10 seconds. Repeat this 5 times. Then switch to the left leg. As this gets easier, maintain the hold for a longer time.
You should feel a stretching in the low back.
Both Knees to Chest
Ly on your back with legs straight. Bring both legs up placing your hands behind your thighs and pulling with your arms so that your bent knees comes toward your chest. Hold this for 10 seconds. Relax the pull for 5 seconds, pull again for 10 seconds. Repeat this 5 times. Then switch to the left leg. As this gets easier, maintain the hold for a longer time.
You should feel a stretching in the low back.
Alternating Knee To Opposite Chest
Ly on your back with legs straight. Bring your right leg up placing your hands behind your thigh and pulling with your arms so that your bent knee comes toward the left side of your chest or shoulder. Hold this for 10 seconds. Relax the pull for 5 seconds, pull again for 10 seconds. Repeat this 5 times. Then switch to the left leg. As this gets easier, maintain the hold for a longer time.
You should feel a stretching in your buttock.
Get on your hands and knees so that your hands are on the floor directly under your shoulders at arms length and your knees are on the floor directly underneath your hips with your knees bent. Begin to arch your back so that your stomach goes toward the floor and your head rises up and your buttock points up. Hold this position for 2 seconds. Go back to the starting position. Next, curl your back so that your back goes toward the sky, your head and neck relaxes toward the floor and your buttock points down. Hold this position for 2 seconds. That’s one rep. Perform 6 to 10 reps. Through out this stretch be sure to maintain the position of your hands and knees and to slowly go through the motion. If you are very stiff, you’ll improve, but slowly, do not force it or get frustrated.
Standing Hamstring Stretch
Standing near a wall or stable furnishing (for support and balance), place the heel of your right leg on a stool or chair. Bring your toes toward your head and maintain a straight right leg, keeping you head and spine upright (no bending to touch the toes). Hold for 60 seconds. Switch to the left leg and repeat.
Notes: If the height of the chair is too much, your stretch will be painful. Find a lower stool to accommodate. The stretch should be felt but not painful.
Hamstring stretches can be done many ways. We recommend this stretch because it is the least risk to the low back. However, if you cannot stand because of your pain, then seek an alternate position to stretch your hamstrings. Why are hamstrings important to stretch for patients with low back pain? If you back is in pain, not only do your back muscles tighten up, but so do you the muscles in the buttock and the back of the legs. If these muscles are too tight, they will pull your spine in the wrong direction, creating a bigger problem.
This is a great start, but tune in again to see the video versions of these exercises.
Dr. Troy Don, DC QME