THE MONSTER LURKING IN YOUR BACKPACK

The Monster Lurking in the Backpack

Although it seems impossible it's already that time of year... I'm seeing mountains of pens, highlighters, folders, and backpacks lining up the entrance shelves of my local general store. Our school district in particular will have an early start the third week of August because of some major construction planned for early summer of 2023.

Parents may be tempted to skip over this blog entry because we've become numb to the fact that backpacks can be a problem. We really shouldn't. There's so much at stake for long-term spinal health and stability that will be irreversible if we don't pay attention to it that the stage. The research article below from 2018 took some interesting measurements that actually quantify the mechanical stress load on the developing spine. The results are not encouraging. However picking a backpack with the right features and occasionally dropping it on the scale before letting you munchkin out of the door can help you mitigate the worst of the problem.

Here is a bit of basic math that illustrates the extent of the problem. According to the authors of the article, the multiplication factor of the weight of the backpack on the actual spinal structure such as a developing disc is anywhere between seven and 11. In plain English, if you have a backpack of 10 pounds, the actual load on the spine is anywhere between 70 and 110 pounds, and a backpack of 20 pounds anywhere from 120 to 220lbs. This is really quite astounding but explains why so many kids will come home saying they're sore everywhere in their back and shoulders. This is even more of a problem if your child has to walk any distances with their backpacks, either from classroom to classroom, walking to and from school, and to and from the school bus.

You only have two real decent strategies to mitigate the issues: first select a backpack that has good padding, wide padded shoulder straps, the waist strap, and all adjustable straps in the waist band, shoulder straps, and possible chest strap. Arguably you will probably get some pushback from you kid about the look they want versus the functionality you want as a parent. Second, grab your kids backpack every so often when they come home from school and put it on your home scale. Wait until a couple months into the school year to do that because the amount of things they have to carry will change, and you'll have a more authentic idea of how much they're hauling around by the time activities and sports roll around.

https://pubmed.ncbi.nlm.nih.gov/30204924/

Wearing orthotics in sandals

Wearing Orthotics in sandals

https://www.youtube.com/watch?v=A0XWv_n73As

Since we recorded the video in June we have compiled a Google document with links to multiple models of orthotic compatible sandals currently available. Please email the staff if you would like a copy sent to you. Is still a very relevant topic as more people are noticing increased foot and ankle pain since going without their orthotics in the hot weather.

WHEN IT FEELS LIKE THE BONES IN YOUR SPINE ARE HURTING, AND THEY ACTUALLY ARE

WHEN IT FEELS LIKE THE BONES IN YOUR SPINE ARE HURTING, AND THEY ACTUALLY ARE

Among the passion filled administrative duties filling the end of the clinician’s year is the annual review of diagnosis coding changes. The infamous ICD-10 codes, describing health care conditions for the sake of insurance billing, research and inter provider communications, get a make over about once a year. There were a few changes affecting routine chiropractic coding this year, and among them, a new code called “vetebrogenic pain”.

I have been around the block long enough to “unlearn” a few orthopedic teachings that were still considered absolute truths when I went to medical school and later chiropractic school in the early 90s. Among them: the spinal disc has no pain nerves (blatantly untrue based on better histology techniques), and thR bone tissue does not cause pain unless it is broken or infiltrated by nasty stuff like cancer and infection. The latter has become more nuanced, as bone tissue pain is much less common than pain caused by other tissues like disc, ligaments, nerves, but nonetheless can happen under certain circumstances, which explains why we have a new ICD10 code to account for it.

The advance in MRI technology and the computerized manipulation of the raw images have better characterized changes in bone tissue from spine degeneration and led to the definition of Modic changes, type 1 and 2. Modic changes are changes in the bony ends of the vertebra that come about with significant deterioration of the disc, either over time or from a major trauma. Modic type 1 changes reflect a very active inflammatory process in the bone marrow, and are highly predictive of associated spinal pain. Modic type 2 changes reflect a fatty replacement, less acutely inflamed, and less strongly correlated to the presence of pain (for comparison spinal disc bulges are seen frequently on MRI but the correlation to the presence or absence of symptoms is almost non existent). Thus Modic type 1 changes can really mean bone pain. Generally described by patient as deep, intense ache that is not correlated well with certain activities, although often worse at night and better with a little bit of movement.

Spinal pain from Modic type 1 changes can be a real challenge to address short term. In the long term, you need to address the root causes of abnormal alignment, muscular balance and body mechanics, but that can take a while. I have found that for many patients, a combinations of high grade botanical anti-inflammatory supplementations, with omega-3, vitamin D and a bone matrix supplement can help pain the chronic pain cycle enough to do more long term restorative therapies.

Sleep apnea untreated

There are two important health issues that are on the apparent periphery of what I do on a daily basis, but their impact on people's long-term health, as well as indirectly on the quality of the recovery we can achieve through our care, is important enough that I often feel the need to bring it up. I did previously blog about one of them, uncorrected acquired hearing loss, and today I want to briefly touch base on the other one, which is obstructive sleep apnea.

For our purposes I would define sleep apnea as the inability to maintain proper respiration during sleep, resulting in insufficient oxygen delivery to all tissues in the body but the central nervous system in particular. Loud snoring or choking associated with the obstructive version of sleep apnea can further disrupt people sleep by continuously waking up the patient.

Ignorance in this instance, is clearly not bliss. The current treatment of sleep apnea is still somewhat rudimentary, mostly using CPAP machines which not everyone feels comfortable using, (with a few emerging alternative options for some patients such as oral appliances), leaving most people to go in denial mode and refusing to be screened and diagnosed. I often have suspicions of sleep apnea based on patient's symptoms, cognitive changes, body shape and BMI, neck and head morphology. I will ask questions, and strongly recommend screening. Some people prefer to brush me off or let my suggestions fall on deaf ears. In this article I have attached a link to a particularly sobering research article which highlights why it's a very poor strategy. Sleep apnea is not just a mild annoyance, it has severe ramifications on premature aging and mortality. By the time the patient may decide to heed the recommendation, the damage may already be done and reversible. Literally down to the level of damaging your genes.

One legitimate concern brought up by some people is how to access meaning and diagnosis. A full-fledged sleep lab testing runs in the thousands of dollars, often a financial strain on patients with high deductible and coinsurances. In some instances when patients have adequate insurance coverage, they do not meet the insurance set criteria to be eligible for the test into first place.

While not exactly an exact replacement, the availability of over-the-counter home sleep apnea screening kits can still fill the gap with pretty dependable screening measurements of heart rate, breathing rate, and oxygen saturation overnight in the comfort of your own home and your own bed.

https://erj.ersjournals.com/content/59/4/2103042

https://www.google.com/shopping/product/1?q=watchPAT+home+test&prds=epd:17928710654120051378,eto:17928710654120051378_0,pid:17928710654120051378&sa=X&ved=0ahUKEwibhsGTzef4AhW7rIkEHZoaACoQ9pwGCAU

Food Reactions: How, Why, Pain, Wellness

https://www.gdx.net/product/igg-food-antibodies-food-sensitivity-test-blood

I have been fielding a lot of questions and requests recently from patients who are trying to pin down food reactions that they suspect are aggravating their chronic joint pain.

The umbrella of food reactions is complex and includes several categories including:

• Reactions mediated by the immune system and manifested as blood antibodies to common food proteins. Those can be tested using IgG antibody blood testing. We use Genova labs at the office and a basic panel costs around $100. Because some of those slow immune mediated food protein reactions can spread over 72 hours post ingestions, the test can be hugely helpful since the correlation to a specific food item is not always readily connected to ingestion.

• Reactions mediated by the interaction of some food macronutrient with the digestive tract: fat maldigestion, protein maldigestion, aggravation of dysbiosis, bacterial, and fungal overgrowth by simple sugars, fiber, FODMAP foods. In those instances, using a GI specific functional markers test will be the best way to work this up along with a good history.

• Reactions to certain chemical compounds found in a food such as MSG, histamines etc. Those can be much trickier to assess by lab or other diagnostics and may require food/ symptom journaling to correlate an ingredient list with a particular timing of symptoms.

SPONDYLOLISTHESIS IN YOUTH ATHLETICS

SPONDYLOLISTHESIS IN YOUTH ATHLETICS

https://www.isjonline.com/article.asp?issn=2589-5079;year=2021;volume=4;issue=1;spage=10;epage=17;aulast=Batra

I came across this article during a continuing education weekend lecture. I was all ears, since I had just been dealing with two very frustrating cases of youth athletics spondylolisthesis cases, which were not being taken seriously by their respective treating providers.

Most people may not have even heard of the term spondylolisthesis, which describes a stress fracture to the posterior elements of the lower lumbar spine. It happens in youth, between ages five and 16, and is not the result of a single trauma but repetitive axial loading with extension and is most commonly experienced with certain type of athletic activities in predisposed teenagers. The problem with youth athletics spondylolisthesis is that some of them will get better with rest and core strengthening, and some of them will not, but my experience as a referring provider is that there doesn't seem to be a very consistent way for the orthopedic system to differentiate between the cases and our youngsters often end up in a one-size-fits-all approach, not always with good results. As a provider who sees a variety of ages, I will often have to deal with the adult and mature adult results of a poorly treated spondylolisthesis in teenagers, long after the juvenile orthopedic system has seen them.

The very first problem is often that the spondylolisthesis is not picked up in the early stages, when the chances of it fully stabilizing and healing without permanent abnormal mechanical faults to the lumbosacral system is available. You can have a strong suspicion from the history, examination findings, and possibly plain film imaging, but ultimately you can only clearly diagnose it with advanced imaging such as MRI.

Assuming under the best of circumstances that advanced imaging has been done in the early stages, the next big issue is determining how likely it is to stabilize within 6 to 8 weeks of immobilization and strengthening. To that I would add obviously the chiropractic approach to look for any underlying mechanical inefficiencies they would add the chance of overloading the posterior elements such as the facets and the bony pars, such as strong pelvic girdle misalignment, short leg, ankle pronation, imbalances in the hip flexors and glutes, cervical facet syndrome with poor proprioception etc.

The research article in the Indian spine journal was really quite remarkable and that it looks at the very objective data to assess which patients are likely to progress to the point of needing surgical stabilization in which ones are not. It is based on total spine lateral weight-bearing plain film x-rays, measuring the angle of the sacrum, on which the spondylolisthesis segment normally rests, lumbar lordosis, and overall cervical to lumbar spine alignment. I had to chuckle since these are the types of mechanical things that chiropractors have been talking about for a long time, and I'm thinking my Indian chiropractic colleagues are probably enjoying a very close working relationship with their respective orthopedic surgeons.

At any rate, for those of you out there dealing with this tricky health issues, whether as a patient, as a parent, as a coach or athletic trainer, know that they are the resources to help you figure out which category you fall into, even if your current provider is not able to direct you with their own toolbox.

CRANIAL NERVE 5, TRIGEMINAL PAIN

CRANIAL NERVE 5, TRIGEMINAL PAIN

Facial pain can be really frustrating detective work to figure out for both patients and doctors alike. I was reminded of that recently with a patient that had been doctoring in multiple places for 18 months, with some unexplained tooth pain, to no avail. In this blog I would like to explore one source of facial pain that is often overlooked and that is trigeminal referred nerve pain from the cervical spine.

I still recall during human dissection in my first year of chiropractic school discovering that unlike most nerves, which were pretty small and elusive, the trigeminal nerve and its node were surprisingly large and easy to find. The trigeminal nerve is part of the 12 cranial nerves which exits through various openings in the skull, unlike the spinal nerves that exit at the level of the vertebral column below. It's a very large nerve with many sensory and motor functions. It affects a huge area over the lateral part of the face from the ear forward. In particular, the trigeminal nerve provides sensation to the upper and lower jaw and the base of the teeth.

What makes the trigeminal nerve unique from a chiropractic perspective is the following anatomical fact: the nerve cell that sends out its long nerve endings to the side of the face starts in the brainstem and dips all the way down in the spinal cord of the upper cervical spine, all the way down to the level of the second cervical vertebrae. As a result, any irritation to the upper cervical spinal cord has the potential to refer sensation to the side of the face. And very often this will localize over the jaw, and the lower teeth.

I'm certainly not suggesting that your first call when experiencing tooth pain should be to the chiropractor, but after a dental checkup, if you still have unexplained pain in the lower teeth especially, diffusely in the corner of the jaw or ear, it's certainly worth having a chiropractic evaluation. Not all upper cervical benign misalignments are likely to cause that, but functional lesions associated with enough torsion and extension can create some irritation of the upper cervical spinal cord and get the trigeminal nerve cells to misfire. This would result in vague unexplained pain in the above areas.

CHIROPRACTIC CARE AFTER SPINE SURGERY ?

That was a question posed to me earlier this week. I was going to refer the patient to some material that I had written about it, but to my great surprise and chagrin, I had done no such thing yet, and it was time to fill the gap.

The answer :

• Depending upon WHICH surgery you had, chiropractic care can resume close to normal after a waiting period of 8-12 weeks. Those surgeries include laminectomies, foratotomies, facet joint partial resection. You can adjust at that segment, obviously with some modification of depth and rotation. For DISC REPLACEMENTS, you need to stay away from the segment replaced but otherwise can adjust adjacent segments pretty normally (I tend to limit rotation and lower the depth threshhold as well).

• For SPINAL FUSION, using graft bone or metal hardware, no manual adjustment within 2 segments is the rule, and you have to wait a full 12 weeks and get confirmation from the treating surgeon that all hardware is secure before proceeding. There is still a lot you can do at other segments, as the fused segment is often a compensatory area in the first place.

• Soft tissue care is still readily available after any type of surgery, so long as the doc or the massage therapy can modify therapy technique to prevent compression of soft tissues onto the underlying bone. Not only is soft tissue care available I frankly think anyone with a prior spine surgery should be evaluated for the necessity of soft tissue care. Scar tissue and adhesions can be a major source of continued pain after surgery when all of the orthopedic imaging shows good results. I especially find cupping useful since it distracts and separates tethered myofascial layers , rather than compress.

• Acupuncture therapy can go on unrestricted, so long as the patient can be positioned comfortably for the duration of the treatment.