WHAT PART OF MY CORE EXERCISES KEEP HURTING MY BACK ?

I've had several back-to-back patients who seem to be stuck in a perpetual cycle of reinjury, forced rest, and forced deconditioning. When we started to pick apart the reason for their reinjury, it became apparent that the patients were doing a whole core strengthening routine, and were not able to really identify which part of their workout may be the problem, and which one may not.

I find it pretty vital to make sure that people are able to keep up with some sort of normal conditioning program regardless of what issue they are dealing with. That will require a much more customized approach than simply releasing them back to their normal routine when they got hurt in the first place. To that effect, I will often spend 10 minutes with patients putting them through 12 simple maneuvers, to watch if any of them cause loss of form and pain. What the patient and I are finding out is that out of the 12, there are usually only one or two that are problem causing, while the rest can be safely done. With alternate maneuvers, modified maneuvers, or striking down that one maneuver altogether, the patient could go back to exercising without reinjury and with a sense of confidence that they can rebuild core strength and stamina. Don't let your fear of your normal exercise program prevent you from staying strong.

Tylenol during pregnancy: clearer links to autism and ADHD

https://birthinjurycenter.org/tylenol-link-to-adhd-autism/

I recently received an email from a nonprofit organization dedicated to the education about risk of birth defects and injuries, who somehow had stumbled upon my blog from a year ago in regards to new research on the risk of taking Tylenol during pregnancy. They forwarded me a link of new research on the risk of prenatal Tylenol use in regards more specifically to the increased incidence of ADHD and autism spectrum disorders in affected children.

The research is much more clearly seeing the correlation, and the 2019 NIH funded study was using objective measurements of Tylenol in utero exposure by measuring umbilical cord level rather than using self-reported measures, historically flawed.

This is bad news as so many women are being directed to use Tylenol for a variety of ailments during pregnancy, under the impression that is safe. There is likely to be a dose-response, meaning that taking one or 2 Tylenol during 9 months of pregnancy may not have an impact. But, I know plenty of women who use it almost daily to manage pain and headaches in particular.

Pregnancy is hard enough, and for some women the idea of not having any sort of pain rescue medication to make it through can be daunting, but I encourage every mom to read this article, pass it along, and try very hard to reach for nonpharmacological alternatives until after the baby is born. Many women still seem to be unaware that chiropractic care is readily available during pregnancy .

https://www.nih.gov/news-events/news-releases/nih-funded-study-suggests-acetaminophen-exposure-pregnancy-linked-higher-risk-adhd-autism

Cluneal Neuritis: A Pain in the Butt that Starts Much Higher

I had a patient last week who got a little testy with me because they thought I was not listening. And for once, I could plead not guilty.

At stakes was an acute episode of pain along the right upper buttock, just above the iliac crest. The patient was upset that I was working higher up in the lower midback, close to the last rib. She thought I did not correctly hear her out when she described her pain.

Pain along the iliac crest, just lateral to the lumbar spine, can be tricky to diagnose because a lot of structures reside in the area, and several neurological structures refer to the area as well. Most of the time, the pain is indeed coming from a local problem (upper sacroiliac, QL muscle, L5), but there is a pesky little sensory nerve bundle that travels all the way down from the lower midback and can cause mischief in the area. The distribution of the cluneal nerves is quite lateral, typically a vague achy sensation that patients have a hard time pinpointing, and sometimes associated with a tingling sensation. Cluneal neuritis will only respond to treatment in the area of origin, which is much higher than the area of pain. That is probably why I most often see it in its chronic stages, when patients have unsuccessfully tried various local therapies.

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.