Breathing Through a Mask and Neck Straining

It has been another interesting week at the office. The ever evolving COVID situation has many folks wearing facial coverings including all of us at the Office. But for many folks getting used to wearing a mask has had some rough patches, especially if you have to be somewhat physically active or talk a lot. Breathing with a facial covering is different than breathing without, regardless of what you try to do intentionally. Our brain is hardwired with some very strong primitive reflexes to decrease the depth and vigor of your inhalation if there is a physical barrier to your airways, to conserve energy and oxygen use during decreased availability. Hence this sensation of being breathless even when the actual venting of your masks lets enough oxygen pass through.

The above fact is instinctively understood by most, but a patient posed me a great question that is understood by fewer: Is there a correlation between use of a facial covering and a sensation of unusual neck straining? The answer is yes, there definitely can be. Several of the anterior and lateral muscles of the cervical spine are “accessory muscles of inspiration”: they are recruited to enhance the efficiency of breathing in, normally born largely by the diaphragm muscle below the lungs. So wearing a mask for a long time, especially when you have to talk or get your heart rate up, will build up over recruitment of the accessory muscles. The sensation of straining will often be felt deep within the neck radiating to the collarbone and into the top of the shoulder blades, and can trigger headaches to the front of the head.

Masks are not going to go away soon or completely, so we better develop some coping strategies.

• Several times a day when NOT wearing a mask, practice some breathing exercises to fully empty out the lungs, such as puffed exhalations, slowly breathing out as far and as long as you can, or blowing up a balloon slowly as big as you can in one breath. This will stop the shallow breathing cycle and retrain your brain to take a full breath. I personally do that during my morning and evening commute to reset my normal breathing.

• Learn to stretch the accessory muscle: dangling one arm and letting your relax to the other side and slightly in extension, or lay on your back with your head hanging very slightly over the edge of the bed.

Post Pregnancy Abdominal Diastasis and Core Strength: Is There an Absolute Contraindication ?

As always daily patient flow is good fodder for blog topics, especially when a question comes up more than once in a week. This week’s theme was diastasis and abdominal exercises. We have had a fair crop of new moms this spring. Diastasis is a fairly common problem. The stretching of the abdominal wall can result in excessive soft tissue separation/stretching between the right and left abdominal muscle group, usually extending a few inches up and down from the umbilicus. It is sometimes accompanied by pain when contracting the abdomen but mostly it is non painful, however the new mom will notice the gaping area and sometimes an outward bulging.

The standard recommendation is to avoid any form of abdominal strength exercises. And while I think that is a very appropriate recommendation for 6-12 weeks after delivery, I take issue with it as an absolute recommendation for all women long term. There is a strong potential negative impact on the spine from limiting core strength building, and not all women have a manifestation of diastasis that will get worse with some form of abdominal strengthening exercises.

My approach is to assess each woman individually in the following way: first, palpate the resting width of the diastasis with the patient laying on their back with their knees slightly bent. Next, keeping my fingers in each side of the gap, have the patient engage their abdominal muscles in a variety of ways: table top leg lift, crunch, and plank. In each position, I will compare the starting width of the diastatis with the exercise width. If the distance increases, the exercise is making it worse. If the distance stays the same and the patient has no pain, the exercise is value neutral for the diastasis but not unsafe, and can be done beneficially for the lumbar spine. In many instances, the distance will actually decrease, suggesting that the exercise is actually beneficial in reducing the diastasis gap over time. In the past 10 years since I started assessing patients in this way, I would estimate that more than half of the patients actually see a benefit from finding the right kind of abdominal exercise. So remember that blanket recommendations in that regard are worth revisiting for your individual case.

The Relationship Between Cervical Spine Disc Degeneration and Dizziness

https://cdn.journals.lww.com/spinejournal/Abstract/2017/04150/Mechanoreceptors_in_Diseased_Cervical.4.aspx

I have had a couple of cases of dizziness in the past two weeks. In both cases, they were glad to find out that we were actually open. Both patients have had prior occurrences of the same symptoms that have responded well to chiropractic care, and if you have ever been in the same boat, you can understand why the idea of waiting until May 4th is wholly unappealing.

Dizziness is a broad lay term that actually encompasses a range of symptoms from a sensation that the room is completely spinning (true dizziness/vertigo), to a sensation of being lightheaded, off balance, and/or on shifting ground. The former is unlikely to be fully caused by a cervical spine disorder but the latter may well be.

The cause of dizziness can be difficult to pinpoint. I have several colleagues, much smarter than I am, who say the day is off to a rough start when a patient presents with a primary complaint of dizziness or fatigue. Behind the joke is the reality that some symptoms can really be caused by anything and you have to be a very persistent detective to sift through the options.

The part of the brain that integrates you sense of position in space receives input from a variety of little sensors throughout the body. The biggest contributors are the inner ear, the visual system, the joints of the lower extremity, and the joints of your neck. If one of the sensors does not give off correct information, the brain center that processes all the information will get very confused by the conflicting sensory data and the end result can be this sensation of being “off”: lightheaded, dizzy, nauseated, or off balance.

The research paper in question was quite interesting in that it pointed out that the mechanism by which the neck can be a cause of dizziness, in particular in cervical spines with degeneration from trauma, age, or a combination of both. The degeneration can lead to an increase of position sensors in the neck (a protective mechanism of the body to give you early signal of a problem in a previously injured area so you stop injuring it further), and this can create a sensory storm to your brain centers if you add even the slightest bit of misalignment and mal-position of the cervical spine to top it off. Chiropractors have discovered that phenomenon by trial and error many decades ago, long before this research paper, when patients reported a decrease in their dizziness after a cervical spine adjustment. Since dizziness diagnosis is usually a diagnosis of exclusion, a chiropractic evaluation when other causes have been ruled out seems a logical choice.

COVID Creative Home Ergonomics

I have started to notice a trend last week that will probably only get worse during the rest of April, and possibly beyond. Many folks have transitioned to working from home and the transition in some cases was hasty. Office workers especially have gone from a great desk, set up with a correctly aligned screen, keyboard and mouse, chair and armrest, and in some cases, sit stand workstations, to a makeshift work corner in their house where their laptop was haphazardly enthroned. Some patients are coming in with unusual complaints of neck and shoulder tenderness, headaches as the day progresses, and wrist pain. When we dig deeper in the mechanism of onset, it clearly emerges that their home station is causing some physical strain.

Remember that you may be working in this situation for several weeks, possibly months, so you owe it to yourself to spend a little time setting things up correctly.

First: You do not need any fancy set up to get started. You can dust off your bookcases and find a use for a lot of books or boxes that can be used as props to bring screens to the right height.

Second: Laptops and tablets are as always the reason for most of the problem unless you use the tablet and laptop as a screen and retrofit a wireless keyboard that can be maintained at the right level, close to elbow height. Wireless and bluetooth keyboards can be found online with 2 day delivery and cost less than $20 in most cases.

Third: Your mouse also needs to be positioned correctly, if you forget about it you will be feeling shoulder pain very shortly.

Fourth: Continue to alternate sitting with standing whenever possible. For that you will need to set up a second work station to float to and from with your laptop and keyboard. Kitchen counters often are the closest height for that.

Attached are a couple of photos of the makeshift stations at the Demel house. I normally do most of my computer work at the office but with shortening the patient days and facing some increased administrative demands due to COVID19, I find myself putting in several hours at a time with my Surface tablet.

Clarification on the Availability of Soft Tissue Therapy Services in April.

The flurry of State and Federal successive orders about various business closures is confusing for everyone, and I realized earlier this morning that our office has been fielding the same question quite a bit, which means I should probably post that on our social media outlets.

In regards to massage therapy services: as per state orders, routine massage therapy appointments for wellness purposes will be deferred to the end of April. Soft tissue therapy services with Anne Knocke are still available if indicated for medical reasons and with a current valid health care provider prescription. The latter applies to patients who are not currently under chiropractic care at our facility, since our patients have soft tissue therapy services as part of their documented treatment plan. We are prioritizing patients with acute episodes , injuries and deterioration of existing conditions. Please call the office if you have further questions.

Interesting New (and slightly controversial) Findings on COVID Transmission from WHO

https://www.npr.org/sections/coronavirus-live-updates/2020/03/30/823905477/who-official-defends-guidance-we-re-not-seeing-airborne-transmission

I ran out of closets to clean by Sunday morning and decided to unleash my fretting fury on some new reading. I had heard that the WHO had just released a paper on Friday with the most up-to-date evidence on the mechanism of COVID transmission from pooled international data and I thought I could always glean a few insights on a topic that concerns the same flow of patients during our reduced hours of the upcoming two weeks.

The paper was said to have raised a few eyebrows and after reading it I could see why. 

You should all really read it for yourselves, but until you get there, I can give you my “good news - bad news “ personal summary.

The “good news”: The paper reports that droplets from cough/sneeze of affected (symptomatic, asymptomatic, pre-symptomatic ) individuals are contagious and can travel some distance. I don’t think anyone doubted that. But the WHO contends that based on available data to date, they do NOT see evidence of airborne contagion from people just breathing, unless you get extremely close to them. There is a big difference between distancing from people who cough and sneeze and distancing from everything that breathes.  The controversy of that statement is that public health officials fear that individuals will scrap any form of social distancing based on that information, and they feel it is too early to draw that conclusion.  I have no opinion either way on how those findings should or should not affect social distancing recommendation because I am not a public health expert, but the idea that simple breathing may be a lot less contagious than imagined sounds like potential great news.

The “bad news “: The paper also reiterates crystal clear that touch/contact is a big vector of transmission. And that my friends, is probably very, very sobering because social distancing alone will not prevent that route of infection (although it will reduce it by the sheer fact that people are touching each other less). Asymptomatic infected individuals will carry the virus in their nose, mouth, and the skin around it. Humans are naturally very touchy feely with their face and the virus inevitably gets on their hands, and from there, on anything or anyone they touch. The CDC and other public health organizations have determined that COVID can live on some contaminated surfaces for several hours to several days.  To give you an example of how that is a big problem: On Saturday I went to a local grocery store by my house. I stood in line at the entrance of the store, 6 feet away from the shopper in front of me in my little chalk circle on the pavement.  When it was my turn to enter the store, I grabbed a cart from the friendly attendant, who, barehanded, gives me a disinfecting wipe for my cart (so far, so good). I put on my disposable vinyl gloves at the entrance. Of 50 people in the store, only one other person does the same.  The people are all picking up items, looking at them, putting them back down for the next person to pick up. A gentleman next to me scratches his nose vigorously, then picks up a carton of strawberries and puts them back down. Someone next in line grabs the same package, loads it up in the cart and onto the cashier belt, who scans the items with her bare hands. The shopper then blissfully goes home, and most likely, grabs the groceries with bare hands and without any thought of cleaning or sanitizing the goods, places them in fridges and pantries.

So here is the bad news : How many of the folks who touched the same package now in your fridge have touched their face in the hour prior to shopping, and what happens if that person is an asymptomatic infected individual ?

Well, this was not meant to scare anyone but really to educate you about using your resources of mental energy toward protecting yourself from the obvious and not so obvious, but prevalent routes of contamination. I would encourage you to have gloves with you that you can put on as you enter a store and discard upon leaving. At home, lay out the items on a surface that can handle some bleach and wipe down with a 1:10 bleach dilution of equivalent and air dry for 10 min before storing or consuming.

Interestingly enough, the CDC is now considering universal use of masks, not just for sick or potentially sick patients, but for everyone. The idea is not so much that you may not catch something from somebody else, but that if you are an asymptomatic carrier, you would not contaminate other folks, and the probably mechanism is likely that you will not touch your nose and mouth when you have a mask on your face. May the “land army” of crafters currently sewing cloth masks be encouraged to continue their good work.

Rambling Thoughts on the “New COVID Normal” at 424 Mill Street West

The last two weeks have felt like a daily mental whiplash, adapting day by day to a new life and work environment.  I have had just enough time and energy to update the blog and social media sites with a few blurbs as we go. Today is offering me an opportunity to finally put some linear thoughts together.

I am blessed to report that our household is doing fine, with no illnesses and no urgent unmet needs (stocked up on TP 3 weeks ago during a routine trip to the store).  Through a stroke of good luck, Kim also routinely stocked up on hand sanitizer and office TP about 5 weeks ago. Bleach goes a long way (1 gallon makes 15 gallons of strong sanitizer spray!). Disposable gloves by the thousands were readily available from restaurant supply stores, and somehow, we had stocked up on surgical masks in December. The staff has made themselves a little “COVID fortress” at the front desk to keep a 6 foot distance during interactions with patients. They have instructed more people to immediately wash and sanitize their hands upon arrival than a seasoned kindergarten teacher.

Like all health care offices, we have been reassessing daily what we should do, if we should do it, and how to do it safely. After much deliberation and informed by recommendations of various public health agencies, we decided to remain open with restricted hours and strict new infection mitigation procedures (posted on website ).  It is certainly not business as usual but it is services nonetheless. Patients with absolute contraindications to travel outside the home are rescheduled to mid April, patients with wellness concerns mostly opt to defer to April as well. This allows us to maintain staggered appointment times for folks who need to be seen in the next two weeks.

As I constantly second guess myself about any decision I have made in the past two weeks, daily life at the office seems to keep me on track.  Governor Walz’s stay at home order that went into effect on Friday included chiropractic services in the list of essential health care services.  It reminded me that a week ago, I stayed at the  office until 8  pm to treat a PCA who works with disabled young adults and was hurt pulling a double shift since other PCAs were out on quarantine. Her next step was probably the ER or urgent care, and she had nobody to cover her next shift.  Thankfully most appointments last week were not that kind of nail biters, but I have come to realize that for many folks coming in, deferring treatment for a couple of weeks will result in non-regainable deterioration of their condition, difficulty keeping up with their job (think grocery stockers, delivery drivers, and young parents), and increased risk for ending up in an overloaded acute care health system. So for now we plod along with a lot of bleach, and a willingness to adapt every day. 

Before parting, please allow me to share a few insights. The bad: the reality of the situation is that life will not just go back to normal magically after April 10th.  The two week sheltering order is time to plan the next phase, in particular how we emerge from the shutdown to a safe “new normal”.  There is a breadth of non-acute health care services that need to resume (think dental, optometry, addiction treatment, preventive care), before they turn into a heap of acute and late stage problems.  Some of the patients we are deferring now fall in that category and we need to find a way to expand access to those folks before too long.  The good: folks out there (or more accurately in there), seem to finally take the social distancing recommendations to heart and this will pay off in a couple of weeks.  There is more information coming out about what truly transmits COVID in asymptomatic and presymptomatic patients (will post link on site tomorrow) suggesting that outside of aerosol droplets from coughing or sneezing, normal breathing is much less of a vector than contact/touch. So being ruthless about what your hands touch and how diligent you are to keep your hands clean before you touch your face is a great way to prevent infection.  I started wearing disposable gloves anytime I enter a store and discard in the trash as I exit. I wipe down everything I bring in from the store with the 1:10 bleach solution before bringing them in the house.  These measures are annoying and time consuming, but in the scheme of things, a small investment for a great return. 

Many blessings and virtual hugs to all. Know that behind my surgical masks, I am still smiling at all of you. 

Fiona Demel DC

Increasing Food Allergies in Children: What Are Some of the Drivers-

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4528619/?fbclid=IwAR0ePaWUz3ZZy1iFc_vSjTOtMz6qnTkUitqh41Ik4sF4zgWQkzKtaD1gDEY

Dr. Alvarez headed out on maternity leave at the end of last week. It was a chaotic time between wrapping up the treatment plan of some of her patients, transitioning those still needing care into my schedule, planning an enhanced infection control plan, etc… However my most important parting thoughts on Friday evening were still to spend a few minutes with Kaila ensuring that we have a good plan of action to check on her before she heads into labor and talk about baby health issues post delivery.

So baby health issues were still floating in my head as I was cleaning out the bowels of my inbox and came across this article that a friend had sent me last year. I had meant to post it ever since then but it must have been buried by another couple hundred emails before I got to it.

Food allergies and intolerances are truly on the rise, not just diagnosed more often. Some are severe and lead to immediate, recognized reactions, and some are slow, chronic, rolling into each other in a way that patients cannot clearly attribute their symptoms to one food or the other (and thus testing becomes really useful). The loss of oral food tolerance is certainly driven by many, many factors in our environment, but today I want to focus on a single one that is not getting a lot of attention: early infancy prescription of antacid for reflux medications.

Reflux in babies is not uncommon and can be frustrating to deal with. It is usually a diagnosis of exclusion with babies being generally fussy, averse to laying flat on their back, coughing after laying down, and sometime regurgitating a lot after eating. Reflux in babies is really an autonomic neurological issue with poor closing of the valve between the stomach and esophagus, but the mainstay medical treatment is with antiacids. It does offer relief from symptoms of the stomach acid coming up the esophagus, but it does so at a cost.

The mechanism by which acid blocking medications increase the development of food allergies is not completely understood but the theory is that the medicines lead to poor breakdown of protein in the stomach due to lowered acid, and that those larger proteins hitting the small intestine irritate the small bowel lining and can get across the intestine to the blood stream where the baby’s immune system will recognize them as foreign proteins that need to be fought off, much like a virus.

While the acid blocking medication may sometimes need to be used as an immediate short term treatment while you look for other ways to resolve the reflux, the goal should always be to do it for the shortest period of time. Chiropractic can be of help in many babies with reflux by looking at the neurological integrity of the upper cervical spine from birth straining.