Quads and chronic postural low back pain

Quads are a big muscle group that is often below our radar. We use them every day every time we walk even a few steps, but since it does not often cause direct pain, we can overlook the way it can contribute to problems in other areas.

One of these “other areas” would be the lumbar spine. The upper fascial layers of the quads extend into the hip flexors deep in the anterior lumbar spine. The hip flexors and the muscles in particular bear much of the blame for causing anterior lumbar spine shifting and secondary compression/extension of the lower lumbar discs, but the quads can do the same thing. The diagram does a fairly good job at depicting the shift in the lumbar posture. Incidentally, this also causes some overload lengthening of the hamstrings and could be a silent source of constant straining of the posterior thigh.

Heavy use of the quads during certain type of occupations (construction workers, laborers etc…), with little rest in between, seems to be a common trigger for chronic myofascial shortening of the quads (whereas muscle shortening is more often triggered by prolonged sitting). You can pick up on the problem when placing the patient in a stomach lying position and bending both knees to 90’. With normal quads flexibility you should be able to achieve that without causing recruitment of lumbar extension or lateral shifting of the glutes. In patients with short quads, you will start noticing some strong resistance, lumbar extension and side gliding of the thigh as early as 45’.

For patients with very short quads, traditional stretching may not be the place to start since you can further aggravate lumbar extension in the process. You may need to start with more passive lengthening therapies and adhesion break up using a foam roller in the prone position for the entire length of the muscles.

Guillan-Barre Syndrome- Acupuncture and Chiropractic

The people reading this blog are going to fall squarely in two categories: those who will raise an eyebrow and a “huh?”, and those who will really pay attention. I don’t often blog about lesser known medical topics, but after a couple recent patient encounters, thought it would be worthwhile this time.

Guillan-Barre is an acute auto-immune peripheral nerve disease, usually post-viral. It can cause profound, severe and rapid loss of motor function in the limbs, face, spine, as well as profound loss of sensation and tingling. While most patients eventually recover, some continue to have persistent weakness in limb or face, and commonly continued neuropathy in the hands and feet, for years after the acute illness. Beyond the initial medical treatment with immunoglobulins, and rehab, patients do not have a lot of medical options for the residuals.

Acupuncture and chiropractic combined, along with an anti-inflammatory diet and some target supplementation, can make a big difference in the residual symptoms of Guillan-Barre. All of us field practitioners would like to see more published large scale studies, but til then, here is a nice case study

https://www.sciencedirect.com/science/article/pii/S2095754817302272

Chiropractic as Part of an Anti-Opioid Strategy

https://www.ncbi.nlm.nih.gov/pubmed/29843912

This great piece of 2018 research has probably not received the publicity it deserves, especially not in light of the sobering stats released from the last 2 years on opioid related deaths in the US, showing little abating. The prescription medications that a patient receives at the time of a first major injury or other musculoskeletal event can be a “gateway drug” to start an addiction cycle that leads patients to street drugs and their lethal potential. And so the need to look at all first line non-opioid interventions in those cases. I rest with a little comfort that our profession is doing their share in trying to reverse the tide.

Birth Related Mild Neck Injuries and Their Widespread Domino Effect

http://www.danmurphydc.com/wordpress/wp-content/uploads/archive/2004/Article_32-04.pdf

Calving and lambing season has already started based on what our farmers are telling me. At our office, I often joke that we have our “lambing” season of sort, with crops of new babies arriving periodically. The last little one I saw on Friday reminded me of this article that I saw at my alma mater’s homecoming in early February, and that I have wanted to blog about ever since.

As one new mom aptly put it, birth is “an awful lot of contorting in a very small space”. Even under the best of circumstances the path from the in utero position to the outside world through such a narrow passage with lots of possible obstructions and delays, and the in utero position itself, head down in a small funnel for weeks, can be its own problem before the first contraction begins.

The 1992 article from a German surgical center is still incredibly relevant today. I could not load up the original (in German and before the internet cataloging), but the summary article from Dr. Murphy does it justice. These are some major takeaways:

• Upper cervical injuries are extremely common, ranging from very mild to more severe.

• There is a consistent, recognizable pattern of postural distortion in a newborn that affect not only the neck and head, but also the posture and development of the pelvis and feet.

• Rigid head extension is one of the most common postural distortions (emphasis mine). This often means the the newborn will be averse to laying on their back and will scream in the car seat, because of painful pressure over the occiput. This is also the frequent cause of the occipital bald spot, with excessive friction of the skin when the head is extended too far.

• There are neurological and autonomic issues secondary to the occipital sprain, including feeding difficulty such as reflux and spitting up, and sleep difficulties.

• Carefully applied manual therapy is the best treatment.

Shoveling safety tips

I am on my third round of shoveling today at home, and could not think of a better topic to review, since it appears that we have one more round of snow coming in a few day. I see a lot of snow clearing injuries, and while not all can be prevented, many can. It comes down to being prepared, having enough time for the job, the right clothing, the right tool , and remembering to use those pesky quads muscles

https://www.consumerreports.org/cro/news/2014/03/snow-removal-shortcuts-that-save-time-and-energy/index.htm

When Is It A Good Idea To Think About Chiropractic Care?

https://www.mensjournal.com/health-fitness/5-times-you-should-see-a-chiropractor-joint-pain-headaches-and-back/

CHIROPRACTIC AND MEDICARE COVERAGE: 2018-19 legislative proposal

https://www.acatoday.org/Advocacy/Legislative-Regulatory-Policy/Medicare

In the very complicated world of health insurance coverage, one little detail that is often lost to consumers is that Medicare is a beast of its own. The commercial insurance market of employer based insurance and individual policies is governed by a combination of state and federal laws. In that regard, those types of insurance are more nimble to changes in coverage. When it comes to Medicare however, this is a federally regulated benefit.

The basic Medicare chiropractic benefits were established in the 70s by Congress, and basically, they have not changed since then, in spite of the evolution of our profession to provide increased levels of complex care and long term management to our senior population. Currently only spinal adjustments for acute conditions are covered, while most commercial health plans provide a more comprehensive coverage ( albeit still with many limitations) to include evaluation/management services, supportive therapies, and extraspinal extremity care.

My standard response to patient frustrated with their Medicare benefits for the past 24 years has been to talk to your elected federal officials, since they are the only ones able to change that. Up until recently, there has been been very little interest in doing so, but the times are changing and more access to primary neuromuscular care is definitely on everybody’s mind, mostly for cost containment purposes. Our national association is making it easy for you to contact your federal reps and let them know how much you support this initiative.

Part Three: Mattress

Mattresses, even more so than pillows, are subject to personal preferences.  When probed about it by patients, I often turn the question around: “If you think back about the different beds where you have slept in the past couple of years, at home and while travelling, what has felt the most comfortable to you?”. Patients sometimes need to be reminded to trust their instincts about what their body is telling them. There is a stoic mentality out there that you need a very firm mattress to support your spine. That is not entirely true. You do need a mattress with a supportive core, and one that does not fail prematurely in the center, but most people feel better with some degree of softness on the outside. The trick is to figure out how much works best for you.

There are a lot of arguments about which mattress material is best, and I don’t plan to add to that. Options range from traditional coil to layers of various materials, to structure foam of synthetic or natural origin. The durability, and often the cost of your mattress will depend upon the quality of the base material and the density of the core, especially the coils.  Structure foam options are popular right now, but you need to look closely at the density per square inch on the manufacturer site, since that is highly variable and ultimately determines the firmness.  Regardless of the material you chose, I recommend that you get a mattress with relatively little top layer built in and retrofit it with the top layer of your choice. This will give you the option to better customize the mattress and change the top layer halfway through the lifespan of your mattress.

From a general health standpoint, you also want to keep in mind that the newer foam materials tend to gas off a lot, especially with the fire-retardant coatings. If you are more sensitive to chemicals, you should consider the newer wool, natural rubber foam options, which unfortunately come at a steeper price point. At a minimum, you should let your new mattress gas off in a well-ventilated area for 1-2 weeks before use.

The type and thickness of the top layers becomes really crucial for patients with wide shoulders, wide hips, or any ongoing issues to the above two pressure points (shoulder impingement, prior shoulder surgery, prior hip replacement, or chronic bursitis). Less than 2 inches is usually not going to be sufficient.

The life span and support of a mattress depends a fair amount on the base of the mattress. I am not a fan of the standard box springs. They fail faster than the mattress and are mostly responsible for the middle sag of aging mattresses. The traditional European slat system is getting more readily available and cheaper. It provides an excellent combination of support and ventilation. A solid base is also an option, but it tends to limit aeration of the mattress.  Flipping the mattress in both directions (180’ and upside down) every couple of months will also extend the life span of a mattress.

As a last note, bed mates sometime have widely different bedding needs and that can be a tricky problem to resolve. One easy option is a mattress with a top layer consisting of two individually controlled inflatable bladders. The other is to install two twin mattresses on a king frame and keep them connected with couple of fitted sheets or mattress protectors. Each side of the bed can be modified with the preferred mattress and top layer, and the transition between the two is usually not a significant barrier.