Here's an all-too-common situation. You develop low back pain that lasts for more than a few days and you're uncomfortable enough to go see your primary care physician. He or she tells you it's not clear what's going on and sends you for a magnetic resonance imaging (MRI) study of your lumbar spine. The study comes back showing one or two herniated intervertebral discs. [Intervertebral discs are cartilaginous shock absorbers interspaced between pairs of spinal vertebras.] Your doctor informs you that you have "herniated discs in your back" and prescribes medications and a course of physical therapy. Your doctor may even refer you to an orthopedic surgeon to evaluate the need for surgery on your back.
Now, all of these recommendations may be necessary. Or none of them may be necessary and all that's needed is some rest and an exercise rehabilitation program that you could do on your own if you were given the proper instructions. The culprit here is how the presence of the herniated disc or discs is interpreted. It's important to remember that not all herniated discs are a problem requiring a solution. In fact, a sizable proportion of such disc herniations (30% or more)1 represent the progression of natural processes and are not a problem at all.2,3 But many family doctors and even specialists are not appropriately trained in accurate differentiation among the various possibilities. When faced with MRI evidence of a herniated disc, such doctors see it as a disorder or disease that needs to be treated and fixed. Such an approach results in significant stress and leads to unnecessary procedures and financial hardship for many patients.
Given the frequency of occurrence of such instances of "over-diagnosis", how can a person with back pain expect to receive appropriate care? Of course, people as patients are usually not in a position to be able to overrule their doctor's recommendations. The answer lies in obtaining relevant information. Let your doctor know you're aware that up to one-third of normal persons have herniated discs, and ask whether it's possible that your disc herniation is in fact unrelated to your back pain and merely an incidental finding. Further, if your back pain is not accompanied by leg pain radiating below your knee, it may be that the disc herniation is not affecting spinal nerve roots and may be treated by very conservative measures such as rest followed-up with exercise.
Thus, not all disc herniations have the same impact on a person's health. Some represent normal findings, even if they are present in a person who has back pain. Let your doctor explain to you exactly why your particular problem requires more than watchful waiting. Your local chiropractor will be able to provide you with the very best expert advice and recommendations for any necessary treatment.
1Takatalo J, et al: Does lumbar disc degeneration on magnetic resonance imaging associate with low back symptom severity in young Finnish adults? Spine (Phila PA 1976) 36(25):2180-2189, 2011
2Spontaneous regression of herniated lumbar discs. Kim ES, et al: J Clin Neurosci 2013 Oct 24. pii: S0967-5868(13)00552-3. doi: 10.1016/j.jocn.2013.10.008. [Epub ahead of print]
3Endean A, et al: Potential of magnetic resonance imaging findings to refine case definition for mechanical low back pain in epidemiological studies: a systematic review. Spine (Phila PA 1976) 36(2):160-169, 2011
The numbers of individuals undergoing total hip replacement and total knee replacement are increasing significantly.1 Annual rates in the United States for total hip replacement have increased more than 50%. In Denmark, rates have been increasing by 30%. Annual rates in the United States for total knee replacement have increased by more than 170%.2 In Sweden, rates have increased 500% in the last 20 years.3 With the aging of the population and increased lifespan, these rates will continue to increase.
Advanced surgical procedures are invaluable, if you need them. Of course, many persons have unrelenting, daily pain which may require radical surgery. For everyone else, though, the best way forward are the old reliables: regular exercise, as vigorous as is appropriate; a healthy diet containing plenty of fresh fruits and vegetables; and sufficient rest on as consistent basis as possible. Regular chiropractic care is also a key component of helping to keep your weight-bearing joints in peak condition.
Many hip and knee problems are a result of chronically poor posture. Almost none of us are taught how to use our bodies properly. We don't come with instruction manuals. So as time goes on, the inefficient habits we develop as children and teenagers become permanent. People slouch, they let their abdominal muscles sag, they stand with all their weight on one leg, and their heads stick out in front rather than being centered over their chests. One result is chronically tight and painful neck, shoulder, and lower back muscles. Another result is chronically uneven distribution of the weight of the body, ultimately causing degeneration of hip and knee joints.
Lack of a healthy diet prevents the lubricating tissues of the hip and knee joints from receiving key nutrients. Lack of proper joint lubrication causes osteoarthritis. Lack of regular exercise inhibits normal joint motion and normal joint nutrition and lubrication, leading to the development of degenerative joint disease. When you add up faulty biomechanics, lack of a healthy diet, and lack of proper exercise, the result is a prescription for chronic hip and knee problems.
For most of us, the best way to prevent the need for a hip or knee replacement is to take consistent, healthy actions on our own behalf. If a hip or knee replacement turns out to be the way to go, all of these healthy actions will help ensure a quick recovery and continued good health from this point onward.
Most chronic joint-related problems involving the hip, knee, and ankle1,2 can be successfully managed with conservative treatment. Surgery for such conditions is typically a last resort and frequently does not work out well. Revision (repeat) procedures are common and represent a failure of appropriate patient selection. Severe, unrelenting, intractable pain is a suitable indication for procedures such as total joint replacement. But the best solution, of course, is to never get to such a set of circumstances in the first place. Chronic joint-related pain is often the result of faulty biomechanics. Abnormal mechanical stresses cause pain. The biggest part of the solution of such problems is learning how to correctly use your personal machine, that is, your own body.
We almost never think of what it takes for our body to work properly until something goes wrong. Usually what's going on physiologically is a seamless process, hidden from our conscious mind. However if we're experiencing chronic joint pain (or, better, at the first sign of such pain), it's time to become proactive.
Mechanical problems involving joints may be conceived as "crossing energies." Mechanical loads (such as forces of gravity) are best opposed by forces arrayed in parallel to, or perpendicular to, the force being supported. Such parallel or perpendicular forces may be thought of as "straight energies." Forces that are not "straight", that is, forces deployed at an acute angle, will cause mechanical stress to a joint over time. Such ongoing stress will damage muscles, tendons, and ligaments, resulting in strains and sprains. If these injuries are not corrected and become chronic, one may begin to experience a great deal of misery.3
Employing "straight" lines of force does not involve actually doing anything physically. Rather, such "straight energies" are activated by a process of visualization. You "see" the straight lines in your mind. To do this, you visualize a straight line running from your hip socket, through the center of your knee, across the center of your ankle, and down to the space between your first and second toes. The straight-line visualization connects your hip socket, knee, ankle, and first/second toe in both standing and bent-knee positions. Your mental image of these straight lines causes specialized nerve endings (proprioceptors) in your hip, knee, ankle, and foot to align these joints and align the mechanical actions of associated muscle-tendon groups. The result is balanced mechanical forces traversing these joints and, over time, reduction in pain. Time may be required for injured soft tissues to heal, but the typical long-term result is decreased pain and improved function.
The "straight" lines of force solution is low-tech and simple. Practice and consistency will go a long way toward successful management of chronic joint-related pain.
1Fox AS, et al: What is normal? Female lower limb kinematic profiles during athletic tasks used to examine anterior cruciate ligament injury risk: a systematic review. Sports Med 44(6):815-832, 2014
2Calatayud J, et al: Exercise and ankle sprain injuries: a comprehensive review. Phys Sportsmed 42(1):88-93, 2014
3Sidorkewicz N, et al: Examining the effects of altering hip orientation on gluteus medius and tensor fascae latae interplay during common non-weight-bearing hip rehabilitation exercises. Clin Biomech 2014 Sep 15. pii: S0268-0033(14)00213-7. doi: 10.1016/j.clinbiomech.2014.09.002. [Epub ahead of print]
If you've ever been involved in a motor vehicle collision, you're probably familiar with the term "replacement parts" or "crash parts". Your auto insurance company will usually offer to repair your car using after-market bumpers, door panels, wheel assemblies, and other parts. Or, you may prefer to have the repair done with parts from the original manufacturer. Regardless of the source of the parts, your car will not be the same as it was in its original condition. It's important to bear the auto analogy in mind if a surgeon has recommended a hip, knee, or shoulder replacement as a solution to a problem of chronic pain.
The frequency of joint replacement procedures of all types is dramatically on the rise within the last 20 years.1 For example, in the United States there has been a 58% increase in total knee replacements from 2000 to 2006. There has been a 50% increase in total hip replacements from 1990 to 2002. Unfortunately, the revision rate (repeat procedures) for total knee replacement more than doubled and revision total hip replacements increased by 60% within the respective, above-noted intervals.
The simple fact is that although your body may appear to be a machine, it is rather an exceedingly complex entity whose whole is much greater than the sum of its parts. Thinking of your body as a machine may be a useful metaphor, one that may aid considerably in medical practice. But the metaphor is not the reality, and forgetting this crucial distinction may lead to substantial and possibly irremediable problems for a patient. Manufactured joints are never as good as your actual physiological structures, no matter the quality of the replacement components.
Of course, there are many circumstances in which joint replacement is indicated and provides great benefit for a patient. However, such procedures should probably be a last resort and never considered standard of care. A best practice would be to reserve joint replacement for situations in which pain is unrelenting and the person has failed several forms of conservative care.
Optimally, in most cases measures are available to avoid such radical outcomes. The best steps for each of us to take is to begin ongoing programs of regular vigorous exercise and healthy nutrition.2,3 Regular exercise, a healthy diet, and sufficient rest will assist all our physiologic systems to achieve peak levels of performance. By making such beneficial lifestyle choices, we help diminish the likelihood of chronic, debilitating pain and loss of function. As a result, we help ourselves avoid the need for replacement parts.
1Singh, JA: Epidemiology of Knee and Hip Arthroplasty: A Systematic Review. The Open Orthopaedics Journal 5:80-85, 2011
2Marley J, et al: A systematic review of interventions aimed at increasing physical activity in adults with chronic musculoskeletal pain--protocol. Syst Rev 2014 Sep 19;3(1):106. [Epub ahead of print]
3Tanaka R, et al: Effect of the Frequency and Duration of Land-based Therapeutic Exercise on Pain Relief for People with Knee Osteoarthritis: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Phys Ther Sci 2014 Jul;26(7):969-75. doi: 10.1589/jpts.26.969. Epub 2014 Jul 30
Do you suffer from neck pain? If you do, you're not alone. Nearly 75 percent of American adults will suffer from neck pain at some point in their lives. And, looking at our anatomy, it's no wonder so many of us do. Though having your head perched on top of your spine gives you a great view of your environment, the set-up is rather like propping a bowling ball atop a tower of blocks. The price? Our necks are prone to injury of the muscles, ligaments, tendons, and joints. But by paying attention to our posture, doing regular stretching and strengthening exercises, and visiting our chiropractors, we can help keep our necks pain-free.
Neck pain ranges from mild (annoying and distracting) to severe (incapacitating). Poor posture during normal, everyday activities such as watching TV, using a computer, reading a book, or talking on the phone can easily trigger minor neck pain. TV watching can be particularly bad for the neck if you're lying on a couch, with your head propped at an awkward angle for a prolonged period of time. Holding the phone between the jaw and shoulder (rather than in your hand), reading at a desk or table with your head hung over a book, or working with a computer monitor below eye level can also be particularly stressful for the neck. By resting and making efforts not to repeat the offending stresses on the neck, minor neck pain usually disappears on its own within a day or so.
Neck pain that won't go away or keeps coming back can signal a more serious underlying problem. Subluxations or joint restrictions; injuries such as whiplash; diseases like osteoarthritis, meningitis and tumors; congenital malformation; and degeneration (such as that in arthritis) require more than rest. A trained healthcare professional such as a doctor of chiropractic (DC) can help. He or she can determine whether the cause of your neck pain is minor and easily treatable or more serious and requiring more intensive, extended treatment. Then he or she may recommend chiropractic adjustment, massage, natural anti-inflammatory supplements, and/or strengthening and stretching exercises. In some cases, the DC will refer you to a specialist.
How can you avoid the need for treatment in the first place? The first step is to take note of your everyday posture. If your job requires a lot of phone use, consider wearing a headset. Do you slouch when you watch TV? Lie on the couch? Choose to sit upright, in a posture-supporting chair. When studying or reading, avoid putting the book or magazine on a flat surface. Instead, consider using a book prop. And, if you notice your computer monitor is below eye level, elevate it by placing it on top of a shelf or tower.
If you experience neck pain that doesn't abate within 24 hours, seek the advice of a trained healthcare specialist for the appropriate diagnosis and treatment. And remember, because chiropractors specialize in the neuromusculoskeletal system, they are some of the most well-trained healthcare professionals to consult about neck pain.
Trigger points are painful nodules in muscular tissue, commonly found in the upper back, low back, and gluteal muscles. Trigger points are frequently chronic, persisting from day to day without much relief. When someone says, “My muscles are all in knots”, those knots are most likely trigger points.
The formal definition of a trigger point describes a localized region of tenderness, located in a tight band of muscle, which is associated with a palpable twitch in response to deep pressure over the tight band.1 Such deep pressure usually results in pain radiating from the trigger point to the surrounding soft tissues. Formally, if the twitch response is not present, the localized muscle tightness cannot accurately be termed a trigger point. It may also be argued that characterizing a local muscle “knot” as a trigger point requires the presence of the above mentioned radiating pain. These definitions are of importance when making decisions about appropriate care for painful muscle knots.
As with any care management decision-making process, some procedures make sense and others do not. Many so-called pain management physicians will recommend injecting painful trigger points with an anesthetic or even botulinum toxin.2,3 Such an invasive procedure is rarely required. Pain management practitioners and even specialists in internal medicine will recommend muscle relaxers such as Robaxin, Flexeril, or even Soma in attempts to diminish muscular pain in the shoulders or low back that may or may not be associated with the presence of trigger points. The problem with such medications is they do not address the underlying cause of the painful muscle knots. Further, their efficacy with respect to muscular pain is questionable.
The mistake, as is frequently the case, is in thinking of trigger points as a real entity. But trigger points do not exist in a vacuum. These painful muscle knots arise as a consequence of mechanical disturbances and stress in the rest of the body. Attempting to treat the trigger points themselves with injections or medications misses the real problem. Trigger points have arisen in a person’s shoulders or low back owing to chronic issues elsewhere, typically involving the spinal column itself and the small muscles that enable those vertebras to move in three-dimensional space.
Trigger points are best managed by directing care to the underlying issues, primarily involving loss of full mobility of spinal vertebras and resultant inflammation in spinal muscles. As with many other biomechanical problems, chiropractic care is often the best solution. By utilizing a specific, highly targeted, noninvasive approach, chiropractic care helps alleviate the factors that have led to the painful muscle spasms known as trigger points. As the underlying biomechanics improve, the trigger points themselves begin to resolve, all without the need for injections or medications.
1Fernández-de-las-Peñas C, Dommerholt J: Myofascial trigger points: peripheral or central phenomenon? Curr Rheumatol Rep 16(1):395, 2014
2Kim SA, et al: Ischemic compression after trigger point injection affect the treatment of myofascial trigger points. Ann Rehabil Med 37(4):541-546, 2013
3Zhou JY, Wang D: An update on botulinum toxin a injections of trigger points for myofascial pain. Curr Pain Headache Rep 18(1):386, 2014
Many people experience radiating pain as a component of neck pain or low back pain. A person with neck pain might have pain that radiates down her arm, possibly into the hand.1 A person with low back pain might have accompanying leg pain, possibly traveling into the foot. Such arm/hand pain or leg/foot pain can represent a serious underlying health problem. However, not all types of radiating pain are of equal importance. The key is to be able to identify which patterns require prompt attention and which merely appear to be significant but are not.
Authentic radiating pain is most often caused by pressure and/or irritation of a spinal nerve root.2 The spinal nerve becomes inflamed and sends pain signals to the brain that are interpreted as pain in the region of the body supplied by that nerve. Inflammation of a certain spinal nerve in the neck region will result in the experience of pain down the outside of the arm and forearm and into the thumb and possibly index finger. Inflammation of a certain spinal nerve in the low back causes the person to feel pain traveling along the back of the thigh and calf and into the fifth toe.
Specific patterns of radiating pain are associated with inflammation of specific spinal nerves. Such inflammation may be typically caused by pressure from a herniated intervertebral disc. Other disorders which may create local space-occupying pressure need to be considered as well. A thorough history and physical examination will help to identify the cause of the problem. X-ray studies may be needed, as well as an MRI scan. The underlying problem, including the pattern of pain radiation, may be termed a radiculopathy or radiculitis.
But most cases of what appears to be radiating pain are not, in fact, related to pressure on a spinal nerve. Most patterns of radiating pain are not associated with a radiculopathy or radiculitis. Rather, the large majority of pain patterns involving the arm/hand or leg/foot are caused by normal, everyday aches and pains. Our run-of-the-mill physical problems involve relatively large muscles such as the trapezius (overlying the upper back, shoulder, and mid back) and relatively small muscles such as those that overlay the spinal bones themselves and help move the spinal column. Ligaments that hold bones together and tendons that attach muscles to bones may also be involved in these everyday ailments.
Irritation and inflammation of muscles, ligaments, and tendons may cause more difficulty than mere soreness and tightness. Such inflammation may also cause radiating pain, but in broader, more diffuse patterns than those caused by inflammation of a nerve root. A person might experience neck pain with arm and hand pain, or back pain with leg and foot pain, but in a broad pattern not associated with a spinal nerve. This is actually good news for the patient, as such forms of radiating pain (known as scleratogenous patterns), are usually more easily treated than those associated with a radiculopathy or radiculitis.
The bottom line is that your chiropractor is experienced in the diagnosis and care of such problems. Your chiropractor will be able to determine if your radiating pain is associated with muscles, ligaments, and tendons or if it is related to pressure on a spinal nerve.3 Your chiropractor will make specific recommendations for care of your specific health problem and help guide you in the process of returning to good health.
1Caridi JM, et al: Cervical radiculopathy: a review. HSS J 7(3):265-272, 2011
2Magrinelli F, et al: Neuropathic pain: diagnosis and treatment. Pract Neurol 2013 Apr 16 [Epub ahead of print]
3Mena J, Sherman AL: Imaging in radiculopathy. Phys Med Rehabil Clin North Am 22(1):42-57, 2011
