DORSAL SCAPULAR NEURALGIA

In this discussion I would like to explore an extremely common pain pattern as well as some of the root causes and treatments available.

Many patients will present with pretty intense pain in the inside of the shoulder blade, radiating downward in a "J" pattern that hooks underneath the inferior corner of the shoulder blade. The pain is often an ill-defined deep dull achy sensation that the patient feels starts in the mid back area but is difficult to pinpoint.

When patients manually trace the location and radiation of this type of pain, they're basically describing the path of the dorsal scapular nerve without having ever rather than anatomy book.

The dorsal scapular nerve is a relatively thin but long nerve that is formed by a branch of the spinal nerve exiting around the C5 vertebra it then has a convoluted pathway that has to travel through the metal scaling muscles, underneath the levator scapula muscle, and underneath the rhomboid muscles before tapering off at the bottom of the scapula.

The relatively long and convoluted path of the dorsal scapular nerve makes it particularly vulnerable to single or multiple areas of compression with the resulting pain described by the patient above. Possible areas of entrapment include: at the level of the spine itself around C5, especially common from reverse cervical curves and whiplash type injuries, in the scalenes, underneath the levator scapula which is a muscle chronically activated by anterior cervical posture, and within the rhomboid muscles, which are also very chronically partially overloaded muscles.

If the source of the entrapment and compression to the dorsal scapular nerve happens to be within the rhomboids, the patient will usually have some degree of luck resolving the issue with local intervention. However some of the patients we see with the most persistent pain pattern of dorsal scapular neuralgia happened to be those patients with entrapment higher up, usually within the mid cervical spine and the scalenes, as the pain can be felt only in the thoracic spine and not alert the patient or the provider to look higher up the nerve source for resolution. The source of the dorsal scapular neuralgia can usually be assessed by manual palpation if carefully applying pinpoint pressure over the area of the C5 nerve root exit, within the middle scalenes, or the levator scapula muscle, and fully reproducing the pain pattern in the thoracic spine. As always, treatment of the problem depends on the location of the problem itself, but for the most part a combination of cervical manual adjustments and specific myofascial nerve entrapment release can usually get the job done.

https://www.youtube.com/watch?v=8cH151cJEaI

Muscle therapy to the head and face

https://www.youtube.com/watch?v=hgMdUJiN9zI

I've been receiving a lot of questions about the soft tissue work we do in the head and face, so decided to write a blog and record a short video as a patient reference and resource.

Head and facial pain can be chronic, debilitating and very hard to treat, and often present with chronic headaches, especially migraine headaches. It does require some detective work to get to the source, and that will often involve the spine, especially the cervical spine, sometimes TMJ. However over time, the cervical spine and the jaw will tend to result in secondary muscular compensation in the superficial layers of the head and face, which become an independent problem that will require its own treatment. As you can see from the photos of my old anatomy books, we have a surprising number of complicated superficial muscular layers throughout our heads. It is probably not something that was much on my radar until the last decade, and probably not even something and became much more specific at treating until the last 5 years, as I started incorporating new tools and techniques that were specific to the very superficial and delicate muscles of the head. But the feedback I have been receiving over and over from patient is that incorporating craniofacial treatment along with cervical treatment results in some pretty dramatic overall improvement, especially seems to decrease the frequency and severity of symptoms return. And it's often a type of therapy that patients have instinctively been seeking, in a bit of a "no man's land" of readily available treatments.

This brief video highlights one common type of treatment using a soft tissue instrument called a guasha blade. The advantage of the instrument is that craniofacial muscles are very thin, with underlying bony structures that require treatment with very little compression over a hard base. The guasha blade can be angulated almost parallel to the cranium, allowing for a very gentle lifting and releasing of the muscle with no compression.

Chiropractic and strokes

I do recall writing one of my 1st blogs on the subject, several years back and before we transitioned our website to the current platform, which scrubbed our older and earlier posts.

One our professional trade associations often puts out an update just before the beginning of May, which is stroke awareness month. I extracted the following information from the latest scientific research review. As I'm drafting this blog, I realized that the topic of stroke in chiropractic does not come on nearly as frequently as he used to. Some of it is probably related to the slow dissemination of the research. The take-home message:

– VBI strokes are extremely rare, affecting between 2 and 3 cents per 100'000.

– These types of stroke happen at the frequency whether the patient has seen a doctor of chiropractic or medical doctor prior to the stroke. Leading the researcher to conclude that early VBI strokes manifest as routine neck pain and headache without any stroke related neurological signs yet, with patient seeking care from a variety of providers during the latent period

– The safety of chiropractic care for the types of condition sst commonly treated in chiropractic offices is remarkable, when compared to other therapies for the same condition provided by different providers. For those of you who are new to the science nerds like me, here are some of the references.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4794386/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271108/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2271098/

Bend N' Squeak

Trying to change patient’s ways of doing body mechanics feels like a long hard road, so I decided to enlist Milou’ s help and favorite squeaky toy to illustrate how to safely bend forward with a flat back

https://www.youtube.com/shorts/SqsChsiKDTM

PASSIVE LORDOTIC TRACTION DEVICE FOR CERVICAL CURVE

https://www.youtube.com/watch?v=BibKL5FtPzc

Those who have been patients at our office for a while know that I'm not big into gizmos unless they have been found to have meaningful patient value in the long term. But there are a few staple items that have a high return on investment for home use, and the passive cervical lordotic traction devices (I know it's a mouthful, I used the abbreviation PCLTD) fall in that category.

The device is a rather simple molded plastic shape, that comes in a couple different sizes to accommodate different bodies, that is meant to apply a passive lordotic force in the cervical spine when applied in the supine position, to shape the ligaments of the cervical spine into a correct forward curve. The device are usually very easy and comfortable to use, and require about 3 to 5 minutes application time per day.

Patients were good candidate for the device are individuals with a reverse cervical curve without severe degenerative changes. Those patients will benefit the most from slow reshaping of the ligaments over time. Some patients are not good candidates for cervical traction device, including patients with severe osteoarthritis of the cervical spine, especially with stenosis that is aggravated by any extension position, or bony spurs encroaching in the posterior lateral spinal canal. Other contraindications include certain types of active vertigo, aggravated by posterior positioning of the head and neck.

We have a couple loners in different sizes that will send home with the patient for trial of 2 weeks of home use, to determine if the traction is beneficial and tolerable. PCL to the devices are readily available over the counter for under $20.

SOFT TISSUE HEALTH #7 : COMPLETE MOVEMENT

Last but not least in this soft tissue health series is a nutrient that's not often recognized as such, but when lacking, will have profound negative impact on soft tissue health even when number 1 through number 6 have been provided: complete movement.

Movement is nourishing to soft tissue in the sense that it's an essential signaling mechanism to the central nervous system to direct resources to the particular soft tissue area to deliver nutrients and provide signaling for repair, remodeling and growth. An immobile soft tissue will atrophy and degenerate regardless of how much oxygen,hydration and protein is available in the body.

There are several characteristics of movement that need to be present in order to ensure optimal soft tissue health:

– the quantity: there needs to be enough movement, frequently enough throughout the day ideally. Most patients seem to get that concept

– the range: tissues such as muscles and the tendinous junctions need to experience the entirety of their range from the most contracted state to the most lengthened state. That's often where things go wrong. There are several areas of our bodies that operate in a pretty small range of motion: our daily activities tend to have us hunched in postural stress without counterbalancing activities. Our modern lifestyle is depriving us of a lot of chores that our predecessors had to do to survive their day, and those chores had us moving in all planes. Not so anymore, so intentional full movement exercises like yoga and Pilates can fill the gap.

– The quality: the movement needs to place enough demands ( strength, speed, coordination) on a soft tissue to signal the brain to respond but not to the point of causing full blown injury

– The rest interval: the movement pattern needs to allow for the appropriate amount of rest to allow delivery of nutrients through restored blood flow, and enough time for the body to conduct the repair process from any micro damage associated with usage.

For that reason, it is important to look at your physical activity throughout a typical week, look at what your body is receiving in adequate amounts, and what it may be lacking that should be made up in formal exercise. It will be different for different individuals. Some people will have light cardio built into their day, but very little resistance activities, others will have a lot of strength requirements in their job but completely lacking in full range of motion/ flexibility of most of their joints. You will design your exercise routine to bridge the gap accordingly

SOFT TISSUE HEALTH # 6: ANTI-OXIDANTS AND ANTI-INFLAMMATORIES

SOFT TISSUE HEALTH #6: ANTI-OXIDANTS AND ANTI-INFLAMMATORIES

In this particular blog entry I will discuss some nutrient categories that can be very helpful for the overall management of soft tissue health and pathologies, and may be more recognizable "household names" to patients who have been keeping up with the popular literature regarding nutritional supplementation.

Some readers may wonder why we are only getting to discuss them in episode number 6 of the soft tissue health series, assuming they would be brought up much earlier. However the order in which each set of nutrients has been discussed is very intentional and reflects the hierarchy of needs and priorities when it comes to building soft tissues from the ground up. It's not so much that the anti-inflammatory and antioxidant compounds are not important for soft tissue health, but the fact that patients often try to incorporate them without 1st addressing some more basic metabolic nutrients such as oxygen and amino acids, thus putting the proverbial cart before the horses.

Our soft tissues, from muscles to ligaments to tendons, are in a constant state of turnover, the result of adaptation to our environment (both external and internal), and thus subject to episodes of stress, from such things as repetitive injuries, single traumatic injuries, or heavy training with the goal of causing some minor disruption of muscle to increase bulk. The normal repair mechanisms of the human body will best operate in a particular chemical environment with fewer free radicals and within the presence of inflammatory immune molecules that are supposed to be finally regulated to be released for short durations in controlled amounts, but will have a counterproductive effect if present in a chronic state and at higher levels. Unfortunately, most of the modern lifestyle in so-called 1st world countries predisposes people to chronic low-grade inflammation and depleted antioxidant status through the usual culprits: nutritional inadequacies, environmental toxicities, imbalanced stress rest ratio, etc. the problem with this scenario is that our soft tissues are constantly operating in a sort of chemical soup that's unfavorable to the normal repair and adaptation cycle.

Supplementing certain categories of antioxidants and nonpharmacological anti-inflammatory substances can make sense in that context, especially if the patient is experiencing more chronic or intense soft tissue demands. We have a lot of patients with heavy physical demanding jobs, 6 or more days a week for 8 months at a time, with suboptimal availability of rest for example, some patients with very chronic postural stress that is not easily altered with ergonomic modifications, or some athletes on intense training schedules. Under these types of circumstances, even when addressing the 1st 5 building blocks of soft tissue health, they still come come up short unless adding some botanical anti-inflammatory supplements for example.

Anti-inflammatory compounds fall along different categories, but primarily in the botanical family and in the fat-soluble family. Botanicals would include things such as high-grade curcumin extract, boswellia, white willow. Fat-soluble anti-inflammatories would be in the omega-3 family, vitamin A and D family. You could also make a case for categorizing CBD in the fat-soluble compounds.

Anti-inflammatory compounds also come in different families, the so-called "greens and reds" which are high concentrations of greens and berries primarily, bioflavonoids, as well as the glutathione family which is more of a direct red-ox system. The list is long and exhaustive in reality, with a lot of compounds that have both antioxidant/anti-inflammatory activity but also cross over into immune modulation and neurotransmitter/neurohormonal activity. While the basic nutrients outlined in blogs 1 through 5 are more straightforward for patients to self manage, supplementing antioxidants and anti-inflammatory compounds has a lot more nuances, and may be worth implementing with the support of a healthcare professional for maximum outcomes. It is also important to remember that the supplements will only ultimately be most effective when utilized as an additional strategy on top of a robust foundation of the previously discussed nutrients.

SOFT TISSUE HEALTH #4: HORMONES

SOFT TISSUE HEALTH #5: HORMONES

In this section we are trying to condense a very large subject into a blog size entry, meaning we will discuss general concepts without a lot of details.

In sections #1-4, we covered the nutrients needed to build high quality soft tissues, but now we to realize that nutrients are not automatically uploaded into the complex architecture of our soft tissues without some signaling to do so. Part of that signaling involves hormones.

A variety of hormones impact the growth, repair and remodeling of our soft tissues, and as such, hormone imbalances can be a source of low grade chronic poor soft tissue healing and susceptibility to chronic injuries. Below is a summary of the hormone systems that are more closely connected with soft tissue problems.

·       Gender variable hormones, including estrogens, progesterone and testosterone. These hormones are involved in improving flexibility, quality and growth of soft tissues. Women suffer the bulk of gender variable hormone problems because they experience more hormonal fluctuations throughout their lifetime. Soft tissue injuries and pain can flare up at certain times of the menstrual cycle, post partum, and especially in the first few years of menopause when estrogens can drop pretty steeply. Women may be on long acting synthetic hormones that suppress endogenous production. Both men and women can be placed on hormone blocking therapies for years at a time for hormone positive cancers. Males often will go through the equivalent of menopause, or andropause, but more gradually starting around age 50, and while the sexual impact of andropause gets a fair amount of medical attention, the soft tissue symptoms of decreasing testosterone do not.

·       Thyroid hormones: a huge driver of normal cellular metabolism, active thyroid hormones are crucial for soft tissue repair and resiliency. Ask anyone who has delt with hypothyroidism and they will tell you that every tissue in their body seems to hurt and be intolerant to normal activities. Thyroid disorders can be complex, more widespread than recognized with TSH testing alone, and in many instances, not fully balanced with straight T4 thyroid medications alone

·       Anabolic hormones: there are quite a few hormones that have anabolic ( = tissue building) activity, but for the sake of this discussion I will highlight DHEA, pregnenolone and growth hormones. The first two are more closely related to the gender variable hormones through enzyme conversion. They are part of the system often called “ adrenal” in laymen terms. Their main role is to build up tissue. Chronic stress of all forms can shunt anabolic hormone precursors into the cortisol pathway and negatively affect tissue building: mental stress of course, but other forms of stress like sleep deprivation, chronic nutritional deficiencies, chronic infections, toxic exposure, significant thermal stress, chronic fasting etc .  Medications, especially steroids which are widely used, can significantly depress normal soft tissue buildup by suppressing endogenous anabolic hormone production.

·       Insulin: insulin is often overlooked in these discussions, since most people only associate insulin with blood sugar management and diabetes. Insulin is actually a very complex hormone that regulates anabolic activity in many tissues in response to perceived energy availability ( pancreas releases insulin in response to glucose sensors primarily, but also to fatty acid and amino acids, to determine if the body has enough energy on hand to perform a task, such a building up muscle or releasing a fertile egg).  It needs to be present in a healthy normal amounts in order for other hormone systems to be active ( thyroid in particular). Soft tissue health will be affected if the body is in a state of insulin resistance and high BMI ( and can be aggravated by certain diabetic medications), or in a state of very low insulin production, such as excessive fasting, ketogenic diets etc

The bottom line: hormone imbalances can be part of chronic soft tissue disorders, but hormone imbalances are also delicate to work up and treat, and should be ideally addressed with the support of a health professional.