CHIROPRACTIC, DIZZINESS AND NECK PROBLEMS

I have had a little bit of time recently to look through some research articles that were backlogged in my reading list. I found a couple real gems in the process.

The prevalence of dizziness in patients presenting for chiropractic care with neck and shoulder pain is remarkably high. It's not usually the primary complaint,but is mentioned when we are asking about additional associated symptoms such as headaches visual changes dizziness tingling and hearing changes. Dizziness is surprisingly common with neck pain. There is a good physiological reason for that: the balance centers in the brain receive information from a variety of structures including the inner ear, the feet and ankle, and the cervical facet joints, which are highly affected by the irritation of mechanical disturbances to the cervical spine.

When the balance centers try to integrate information from the various peripheral sensors, if one part of the system sends faulty sensory information that  conflicts with what the inner ear, the visual system and the feet are reporting, It's going to be manifest as confusion in the balance centers and can be expressed as a sensation of dizziness. This is the primary mechanism by which cervical mechanical problems can manifest as a sensation of dizziness. Conversely, the resolution of that faulty sensory information from the cervical facets by manual adjustments can reset the sensory input and make it fully integrate with the rest of the peripheral sensors , thus resolving the symptoms of dizziness.

This research article reflects that reality, with a surprisingly high number of patients reporting resolution of the dizziness from chiropractic intervention while traditional medical evaluation and pharmacological approach does not. It's good news for the chiropractic patient.  Not so much for those of us who have been working in the chiropractic field for a few decades, but it was somewhat of a surprise to the researchers who ran the study.

https://pubmed.ncbi.nlm.nih.gov/26362851/

PROTEIN, PAIN, INJURY : HOW MUCH AND WHAT KIND DO I NEED ?

I had a discussion last week with one of our teens involved in athletics, followed 15 minutes later by a similar discussion with a patient in his 70s, struggling to improved metabolic syndrome and stabilizing old athletic injuries. The common thread was the importance of high quality balanced sufficient protein intake in achieving their goals (respectively mitigating chronic returning injuries and managing diabetes). Looking at my weekly research digest with this particular article at the top come up I knew the universe was telling me to put up a blog about it.

The importance of protein intake comes and goes in the integrated and wellness space. That's unfortunate because it should never leave the discussion .It's just one of those subjects that's not sexy enough to make headlines and money on a consistent basis so it gets cycled through when it's convenient.

For the sake of keeping this blog entry at one page rather than 20, I just want to highlight a few key points in regards to protein intake:

·       The total intake for optimal health and maintenance of lean muscle mass and soft tissue repair is about half a gram per pound of body weight, as a very crude measurement .Which means that for an average adult it's going to be close to 80 grams a day, much less than what most people are getting. It can even go higher in certain needs such as increased physical activity, recovery from illness injury surgeries or other trauma.

·       Quality of the protein is also crucial. It is defined as the diversity and percentage of essential amino acids, defined as those that cannot be manufactured by your body. In that regard animal protein has a much better profile since it belongs to animals, rather than plant based protein which are meant to build up plants. This statement will often cause quite a stir among people who are advocating a plant based diet. But understand that recognizing the importance of the quality of animal protein does not necessarily mean that it makes up the exclusive protein source in your diet. It means that it needs to be present in meaningful amount to provide the needed amino acid mix, but that plant based protein that are part of the plant part of your diet is also beneficial. If you look strictly at the data and the research it's very difficult to get optimal protein intake and amino acid balance from a plant diet alone without resorting to some very fractionated supplementation. My ballpark figure is to get at least half of your protein from animal sources. Ideally flesh based protein should be nose to tail and incorporate not just muscle meat but organs and connective tissues, As well as sea and land animals.

·       Incorporating animal protein can be done with respect to environmental and animal welfare concerns. In that regard we are very fortunate in our zip code to have access to ethically raised and properly fed sources of animal protein.

·       Incorporating optimal amounts of diverse protein in your diet will also have a beneficial effect for weight management. Our brains are engineered to continue eating until we have extracted enough essential amino acids from our food. Thus our brains are less likely to continue hungering for calories if the total amount of essential amino acids has been met. Conversely, if the amino acid density is low, your brain is going to signal you to continue eating more food,  thus calories until you reach that sufficiency point.

·       Protein sufficiency is important at every age but in the instances of the two patients I saw back-to-back, for very different reasons. Our athletic teen kept having recurrent tendon and muscle injuries because she was grossly deficient in adequate protein for normal repair during a high intensity season with daily 2 hour practice. Our 70 year old with metabolic syndrome was seeing low results from his strength training program and poor control of diabetes because he was not able to leverage his exercise into the deposition of lean muscle mass due to suboptimal protein intake. Numerous studies have shown that adequate protein intake becomes more crucial as you age, since our body is less efficient at extracting amino acids and depositing them for the same amount of protein you eat 10 years earlier.

·       The question over protein powder continues to come up as part of the protein sufficiency discussion period my first recommendation is to always get as much of your protein intake from Whole Foods, and supplement no more than 25% maximum with protein extract. This would mean practically that one serving of a protein powder concentrate of about 20 grams per day is OK at times, but should not be the default to meet your protein needs. It is however a very smart move during certain times when getting the right amount of protein may be difficult, such as some of our patients dealing with aggressive treatment with chemotherapy, recovering from oral or GI surgery for example. Protein powders come in very different qualities, and maybe beyond the scope of this blog to discuss. As a general rule you should not use plant based protein for large amounts of protein supplementation due to amino acid balance, and as long as you have tolerance for dairy, whey protein, egg protein, and sometimes hydrolyzed meat proteins may be a better option. However remember that certain simple dietary hacks such as a can of tuna, a cheese stick, a couple of boiled eggs can give you a pretty good 10 to 20 gram boost with not a lot of calories.

Chiropractic and the stellate ganglion

A good friend of mine asked me a question about the stellate ganglion in regards to a family member’s injection procedure and asked me how chiropractic interacts with that structure, which reminded me that at some point I had wanted to write a quick blog about it.

The stellate ganglion is a larger node of the autonomic nervous system that is deep in front of the lower cervical spine. It's a large cluster of peripheral autonomic nerve cells that are involved in regulation of several important autonomic functions in the neck and chest including: heart rate and regularity, opening and closing of the blood vessel in the upper extremities, some pain perception and anxiety threshold, regulation of tears and saliva production.

The stellate ganglion is of interest to chiropractors because of its proximity to the anterior lower cervical spine and the fact that it's sensitive to injury especially from rapid extensions such as whiplash. This may explain some of the symptoms that patients often report after an extension cervical rapid injuries such as palpitations, nausea, abnormal cold and hot sensation in the face and hands, feeling anxious, unusual runny eyes nose or dry mouth.

Manual adjustments to the lower neck, upper back, and anterior first rib as well as deep tissue myofascial release deep in the anterior lower cervical spine can have an impact on the regulation of the stellate ganglion and associated autonomic functions. I have found in 30 years of clinical practice that especially addressing the muscular injuries of the anterior cervical spine in patients post whiplash and concussion can make a huge difference in long term symptom management. And I believe that some of that impact is probably due to relieving stress on the stellate ganglion from Injured and scarred surrounding soft tissue structures.

Chiropractic and "wallet talk": hard data on the cost effectiveness of chiropractic care

https://chiromt.biomedcentral.com/articles/10.1186/s12998-024-00533-4 

It's that time of the year where the infamous insurance deductibles kick in again, and with it the frustrating realization of how expensive Healthcare is in the US. I tend not to talk about it very much in my room to focus on patient clinical care, but making decisions about health care sometimes brings up that discussion as patients are having to strategize and prioritize seemingly infinite healthcare cost on a finite budget.

As our own household has seen our deductible soaring to new heights, I have found myself a little more capable of engaging those discussions with a sympathetic ear and a nod of solidarity.

This particular research article on the cost of healthcare comparing traditional medical point of entry versus chiropractic care point of entry for multiple common neuromuscular skeletal problems was quite enlightening in several ways.

-The cost of chiropractic care itself tended to be on the lower end for the initial course of care, although not by a whole lot if you compare side by side the first six weeks of care.

- the overall cost of care downstream meaning for the months and years after the initial course of care was however strikingly lower in patients who started their health journey through the chiropractic point of entry. This was primarily because the secondary medical costs associated with imaging, medication, other mid level and surgical interventions was significantly reduced. In practical terms this means that starting to address your issue by working with a chiropractor means that you're less likely to escalate to need a variety of other expensive services. This is something that has often been reported to me by patients: working through things conservatively with a chiropractor on the front end meant they were able to manage it pretty well in that manner in the long term.

- interesting tidbit that's buried somewhere in the research paper is the fact that there is quite a range of chiropractic cost. Meaning that not all providers are created equal and how well they manage a problem from a financial perspective. This is noteworthy as well, meaning that you need to look at individual providers and their track records to make sure you're not working with an outlier.

Neck pain, anterior neck posture and mouth breathing

I've had a few cases recently of pediatric and adult straight neck with persistent neck pain that didn't seem to respond to the traditional neuromusculoskeletal interventions and I thought it would be a good time to bring up a lesser known contributing Problem to chronic postural neck pain.

A loss of cervical normal anterior curvature and a so-called straight neck can be the result of many factors, including flexion trauma, chronic anterior cervical strain associated with use of technology, and some vestibular cerebellar functional disorders. The interventions supporting the chiropractic treatments can be as varied as the causes themselves, including postural awareness and reset, cervical lordotic home device etcetera.

One lesser known contributing factor to chronic anterior cervical malposition is chronic mouth breathing. Normal resting breathing should be through the nose, since this is the most appropriate airway path to warm up air entering the lungs and filter for debris and pathogens. A person will switch from normal nasal breathing to mouth breathing if there is compromise of the nasal airways, in the form of chronic narrow airways ( narrow hard palate in children especially), chronic congestion from allergies or infections, chronic enlarged tonsils and adenoids, and chronic structural issues with the airways such as severe deviated septum. Positioning the head slightly anterior will actually increase the diameter of the oral airway, and becomes an adaptative posture in many patients with upper airway compromise. In patients with strained anterior cervical spine from mouth breathing, the patient will often notice increase neck pain during  during cardiovascular endurance activities ( which will further strain the airways and accentuate the adaptative anterior neck posture)as well as during static sitting and laying flat on their back. Mouth breathing is surprisingly common and often completely below a patient's radar unless assessed or noticed by somebody around them.

Obviously resolving chronic cervical discomfort in those patients is going to require looking at resolving some of the underlying airway problems. In the meantime however, in addition to the more traditional chiropractic intervention with manual therapy and corrective exercises, retraining the patient to breathe through their nose with efficiency can make a real big difference in stabilizing the cervical complaints.

"Baby hip" pain: smart tool solution

https://www.walmart.com/ip/Baby-Hip-Carrier-CPC-Certified-Extender-Lumbar-Support-Multiple-Pockets-Adjustable-Waistband-4-Positions-Newborns-Toddlers-44lbs-Black/5746450135?wmlspartner=wlpa&selectedSellerId=101684497&gQT=1

Those of you who have known me for many moons know that I'm not a big fan of gadgets, however I do recognize that there are some incredibly useful tools that help manage chronic condition and prevent injuries in the 1st place.

I came across this product at a social gathering recently. Apparently it's been around for a while but must be a well kept secret because I've never seen one of our mom patients show up with one of them, and I've not heard it bragged about as it probably should be. There will many many months during which a child is likely to be held and carried on one hip while the other dominant free arm is tending to things, when a child is fussy and needs to be held. From a chiropractic standpoint, this results in chronic distortion patterns in the pelvis involving rotation and translation that seem to be very refractory to treatment until the child grows into a toddler that no longer gets picked up. (And sometimes that can last until a child is 3 or 4 ).

The hip belt prop has a little platform that can hold a child's bottom, and if the supporting belt associated with the platform is pretty broad and snug, distributes the weight of the child pretty evenly without requiring the trunk to lean the opposite direction. In that manner, you get the best of both worlds: a happy child being held and supported with a loose hand, while mom has a free hand, and  spine and pelvis maintaining pretty neutral alignment. This would incidentally be a great gift to any new parent, if you find yourself staring at one more cute onesie likely to be outgrown in a few weeks on a baby registry.

PAIN AND EXERCISE: GOOD PAIN VERSUS BAD PAIN

“GOOD PAIN” VERSUS “ BAD PAIN” PAIN FROM ACTIVITY AND EXERCISE

 

A question that arises commonly as we tackle the rehabilitative phase of a patient’s treatment plan, is what level of discomfort is to be expected and tolerated when patients start resuming normal activities or pursue exercising when being treated for an acute or chronic condition. In other words, what is the defining line between good and bad pain?

First, we should talk about when we start introducing therapeutic activities in the first place, especially when patients are acute, as some patients are pretty eager to start exercising to get better faster. As a general rule, I may not add much beyond in office treatment and light walking, breathing, general movement and active range of motion stretching in the first week or two of treatment. You cannot inherently strengthen or stabilize something that is completely dysfunctional or structurally misaligned.

Usually by the end of the second week at the latest, we can start adding more specific activities. With the input of the patient, we look to find the right balance between pushing the patient enough to make gains, and not pushing so hard as to reinjure. It can be a bit of a balancing act, and I give the patients three guidelines to stay in the safe zone:

-          There is a difference between pain and soreness. Soreness is a normal reactivation reaction that is more of a generalized discomfort. Sharp pain is normally to be avoided as a sign that you are pushing too far too fast.

-          I like to use the 2 points on the 10 scale rule: during the therapeutic activity, it can be OK to have a little more discomfort than at baseline. For example, if youR pain at rest is a 2 on a 10 scale, it can be at a 4 on a 10 scale, but really you should not let it get much higher.

-          The discomfort associated with the activity should not significantly outlast the activity itself, ideally returning to baseline within 30-60 minutes.  If post activity related pain lasts into the rest of the day, if it interferes with sleep, if it is still present the following day, these would all be indications that you are pushing too hard, too fast, or that the exercise is not right for you.

There is not a one size fits all solution to what discomfort is OK in your situation, and you ultimately need to discuss that with your provider. Some people have underlying conditions that will carry a little more baseline pain during the rehab phase ( inflammatory arthritis, meds, fibromyalgia), that will require creative accommodations. But in the end, where there is a will, there is almost always a way to get stronger.

Photo courtesy of Freepik

Gluteal Amnesia: when your butt muscles forget what they are supposed to do

I have a running joke with a couple colleagues that doing quick strength and stability assessment is trying to find the biggest slacker among our major stabilizing muscle groups. And when it comes to lumbar pain, the gluteals seem to win the prize.

The buttock muscle is a very large muscle group comprised of three major superficial muscles and a couple of smaller deep muscles that are involved more so in guiding movement. They are supposed to fire first and foremost doing a variety of trunk activities including forward flexion, which is when a lot of injuries to the lumbar disc seem to happen. In doing so, the gluteal muscles bear the the load and prevent the smaller lumbar muscles from being overloaded. I do recall from my days of doing dissection anatomy how surprisingly thick they were even in older cadavers, while the lumbar paraspinal muscles were comparatively so thin. As such, the gluteal muscles are really engineered to bear the brunt of the muscular stabilization process. 

When gluteal muscles fail to engage properly and sufficiently, the lumbar paraspinal muscles and associated lateral groups like the QL have to take over. Two things will happen: first, they are not engineered to bear that kind of load and can easily get into an acute or repetitive injury cycle. Second, they tend to create distortion pattern in the lateral curve with hyperextension, chronically loading the lumbar facets. It's a loot lose situation. 

The reason gluteal amnesia is so problematic and so prevalent is because muscles tend to down regulate their normal activity and firing pattern when exposed to prolonged pressure. Such as sitting on your butt the majority of the time. It's a scourge of the modern lifestyle that is probably driving the majority of the gluteal amnesia problem, much more so than direct injuries. The average American spends more of their wake up time sitting at home, work, in their vehicle, than they do ever being up around and moving. There are a few different ways to test for the firing pattern of the gluteal muscles, including the prone swimmers test, bridging, and standing squatting. It's usually pretty obvious. Treating gluteal amnesia involves a combination of trying to decreasing the amount of sitting time, changing the sitting posture to center the lumbar spine over the pelvis rather than posterior to it, which tends to increase pressure over the buttock muscles, frequently engaging gluteal in a variety of functional activities such as squeezing your butt muscles every time you get up and down from a chair, and more structured exercise routines such as bridges and squats.