Chiropractic case studies

Patrick, thanks for your very measured and reasonable response to my ‘moment of frustration’ posting, I thought I'd get the fundamentalists on my case.

However, I think these questions need to be answered:

1. From the petition can Singh or the public continue to:
“criticise assertions (made by chiropractic) robustly and the public should have access to these views”
The answer is unreservedly yes.

2. Again, from the petition, what has the BCA action done prevented
“The scientific community would have preferred that it had defended its position about chiropractic for various children's ailments through an open discussion of the peer reviewed medical literature or through debate in the mainstream media”
The answer must still be nothing – only a perceived prevention as a result of Singh’s spin.

And so, I would challenge you to find one bit of evidence that demonstrated that the BCA are doing anything that would, as an example, prevent Singh and Ernst from publishing another book tomorrow that examined the evidence for and against chiropractic. Yet, the spin is that this action is stopping this from happening. It is not, and anyone can challenge the profession of chiropractic in any medium, in any language, any time and they’ll be safe to do so. What they can’t do is say that personally I am bogus or that the BCA is lying without having to prove it.

Singh should have known better since he's a journo (and as an aside it is intersting to note that the BCA are not taking Ernst to court for his misrepresentations - he seems to be wiser than Singh). Singh made a mistake and he did it in the worst country in the world for libel. But, I also feel let down by him as I enjoyed his last few books and his TV work and by what seems a lack of judgement in using such poor science doloped out by Ernst. Here is the example from the Guardian article:

“In 2001, a systematic review of five studies [oh, yeah, done by Ernst on studies by Ernst] revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.

More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks [proven by what science – the say so of Ernst]. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures [what! – where, when, who? ahhh – good science provided by Ernst and not cross checked by Singh].

Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.” [Controversial stuff and the publishing life blood of Ernst for a decade and it is just poor science to suggest this is the case – and again unchecked by Singh for this ill-considered article]

Finally, the spun Sense in Science petition has the nerve to say:

“Singh's only (only! not what I saw) objection, if you read the article, is evidentially unsubstantiated claims on the BCA website about chiropractic spinal manipulation curing such childhood problems as bed-wetting, colic and asthma. In the end, we have to support his support as a whole whilst examining if he is right to look at unsubstantiated claims”

bloody misrepresentation in my and I hope anyone's book.

The Singh issue has its roots buried deep his financially motivated decision to co-author ‘Trick or Treatment? Alternative Medicine on Trial’ with the crypto-denialist Ernst. Ernst is a poor scientist; the references on his papers seem to refer to a lot of his own work or to other carefully selected cases and neatly ignore the substantial, and it is now, body of evidence which is robust enough to convince NICE that chiropractic is safe.

After leaving the BBC, Singh wrote a series of great bestselling popular science books ("Fermat's Last Theorem", "The Code Book" and "Big Bang") and, as he freely admits, made a fair bit of money out of these projects. And why would Ernst co-author with Singh? because, I suspect, Singh could provide the reputation to get Ernst’s unscientific book sold (Kerching” for Singh). This Singh does with his ill-considered article in the Guardian, which you will notice has as its last telling line:

”• Simon Singh is the co-author of Trick or Treatment? Alternative Medicine on Trial “

(more Kerching for Singh)

Now, he’s a journalist and should know that if in the article he libels a profession then he’s in the clear (i.e.: all doctors are in the thrall of the drug companies) but if he libels an individual or an organization he is not (i.e.: Dr Smith is in the thrall of the drug companies). He made a mistake and was supported by the Guardian – but only for a while. So now he’s scared as all the financial gain from the previous three books (triple Kerching for Singh) look like being sucked up by the law case.

But why the suit? As a summary in the Guardian article Singh says:

“ - if spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.” (unlike paracetamol, celebrex and any one of the COX-2 inhibitors then)

which is entirely based on the utterly piss-poor ‘evidence’ delivered up by Ernst rather than the solid evidence produced such as the BEAM report which said:
“Conclusions: Spinal manipulation is a cost effective addition to "best care" for back pain in general practice. Manipulation alone probably gives better value for money than manipulation followed by exercise. “
UK Back pain Exercise And Manipulation (UK BEAM) Trial
A randomised trial of physical treatments for back pain in primary care.

As well as the MEADE report and the all evidence that convinced NICE to issue its pro-manipulation clinical guidelines only in May this year.

So with this ill-informed, unscientific, drubbing ringing in the profession’s ears the BCA notice that they have been kicked in the book, kicked in the article and libelled in the article, and all for Singh’s financial gain based on discredited science. What would you do?

So, where does Singh go before he goes bankrupt? He creates a media storm, because that’s what he can do, and he repackages the issue (or spin it to repackage the term) to look like this taken from the online petition:

“The British Chiropractic Association has sued Simon Singh for libel. The scientific community would have preferred that it had defended its position about chiropractic for various children's ailments through an open discussion of the peer reviewed medical literature or through debate in the mainstream media.
Singh holds that chiropractic treatments for asthma, ear infections and other infant conditions are not evidence-based. Where medical claims to cure or treat do not appear to be supported by evidence, we should be able to criticise assertions robustly and the public should have access to these views.”

So Singh has managed to spin the issue away from the utter damnation of all chiropractic set out in his article, designed to sell his book (Kerching for Singh), to a freedom of speech issue based about chiropractic for various children's ailments claim by some chiropractors to treat colic and other fringe activity. Neatly done.

And then he got his media friends and science colleagues and you and me to see his side of the story and I think we may have been misled.

Perhaps.

If Singh had spent a bit of time reading round the subject and using his judgement rather than just seeing the £ and listening to Ernst than none of this would be happening.

Studies show that the number of Americans willing to try alternative treatments continues to increase. A 2007 survey by the federal government found that more than one-third of adults and nearly 12 percent of children in the United States used alternative therapies, including acupuncture and herbal supplements.

Many mainstream physicians continue to be skeptical of acupuncture, saying their efficacy has not been proven and their successes may be nothing more than variations of the placebo effect. But increasing numbers of institutions, including Johns Hopkins Hospital and the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center, have established integrative medicine units that bring together conventional and alternative approaches to care.

Health insurers are also beginning to recognize and pay for some alternative therapies, including acupuncture and herbal remedies, although Medicaid and Medicare do not cover them.

"It's not as evidence-based, which is why doctors are somewhat averse to the practice,'' said Shnider, who is affiliated with Cardiology Associates. "But if [they] didn't work, why would we still be doing them thousands of years later?"

Source: washingdonpost.com(By Lori Aratani Washington Post Staff Writer Tuesday, June 9,2009)

Arguably, everyone has had a headache at one time or another and at this moment in time more than 10% of the UK’s population is currently suffering from a headache of one form or another and this is why they are the main reason for seeking advice from your GP.

There are several different types of headache. Over 90% of these types of headache are known as primary headaches which have no underlying medical condition. These include all tension-type migraines, cluster and cervicogenic headaches.

What is a cervicogenic headache?

Cervicogenic headaches are headaches where the pain originates in the neck and upper shoulders and are neatly clinically defined as “pain that is present in the head, but which originates in the cervical spine”.

However, cervicogenic headaches, like other types of headaches are different for different people and, depending on who you are, some are more sever and some are less severe, some are present in the head and others have pain behind the eyes.

The ‘classic presentation’ of a cervicogenic headache is where pain starts in the occipital region (the base of your skull at the back) and in the cervical spine and then progressively spreads upwards into the head.

Commonly, with cervicogenic headaches, there will be muscular trigger points in these suboccipital muscles of the neck and in the shoulder muscles. These trigger points can also send shooting pain to the head when they are physically manipulated and will be very, very tender.

Helpfully, there are two key symptoms that are generally exclusive to cervicogenic headaches. Firstly, the headache can be made worse or actually initiated by head or neck movement or passive neck positioning, especially when extended towards the side that is prone to pain and secondly, there is marked tenderness in the suboccipital region.

Who is likely to get them?

In our experience nearly all patients with cervicogenic headaches have abnormal neck posture (this is nearly exclusively Anterior Head Carriage) or have restricted range of neck motion.

And they are caused by?

We see these on a daily basis and in our experience at C1 Chiropractic Health Centre is that these headaches are a by-product of trauma (such as whiplash), neck injury, intervertebral disc disease, progressive joint arthritis, chronic tension or muscle trauma due to poor prolonged posture or severe stress with this last one being the most commonly encountered headache in our clinic.

How’s it treated?

Unlike many common forms of headaches, such as migraine, and cluster headaches, they often do not respond well to over the counter medications such as analgesics or common pain medications such as Panadol. Although the cervicogenic headache sufferer will note some relief from the symptoms of pain experienced when taking a pain relieving medication, once the preparation has worn off, the symptoms, and pain will return. In order to gain relief treating the symptoms simply isn’t enough and a more holistic approach must be taken for long-term pain reduction.

One of the most effective ways of relieving cervicogenic pain is with Chiropractic treatment using Chiropractic manipulative therapy (CMT). We manipulate the bones in the neck area that have moved out of alignment to reduce inflammation and irritation and so reduce pain.

A major spine care review was published in 2008. The authoritative report by the Bone and Joint Decade 2000 – 2010 Task Force on Neck Pain and its Associated Disorders which built on the impressive report produced Quebec Task Force on Whiplash. This report follows seven years of literature review and original research from more than 50 researchers and the editor of the Spine journal described it as a “milestone” report.

It covers all aspects of neck pain, including headaches, arm-pain and other neck generated symptoms. Tellingly, it states that neck pain is a “multi-factorial and episodic or recurring problem” and adds that because patients have many differing personal factors underlying their problems best management requires informing and educating patients on their options and respecting their preferences.

It then goes on to add that most patients have grade 1 or 2 neck pain (so low grade and therefore ‘primary headaches’) and that treatments, with similar evidence of safety and effectiveness, are education, exercise, mobilization, manipulation, acupuncture, analgesics, massage and low-level laser therapy. But treatments NOT supported by the evidence are surgery, collars, ultrasound, electrical muscle stimulation, TENS, most injection therapies including corticosteriod injections for the cervical joints.

According to recent studies published in the Journal of Manipulative, And Physiological Therapeutics, the results indicated that spinal manipulation had a significant positive effect in cases of cervicogenic headache. In this study, 53 participants who were sufferers of cervicogenic headaches were studied closely. Half of the subjects were given chiropractic manipulation as treatment, while the other half of the subjects received deep friction, and low laser massage. The study lasted over the course of a three-week period. While the two groups of sufferers did notice improvement with the care given to them, the group that were involved in the soft tissue treatments noted only a significant decrease in the hours per day that they were experiencing headache. The manipulation group showed improvement in all three of the measurement criterion being studied. Those who received chiropractic treatment in the study noticed a 36% decrease in their pain medication usage; their headache hours were decreased by 69% and their headache intensity had also decreased by 36%. At the 12 week point, one month after the trial ended, there was “a clinically important and statistically significant” advantage in pain reduction for the patients receiving chiropractic manipulation. The patients receiving 8 treatments had a 9.4 advantage in pain reduction. Those receiving 16 visits had a 17.2 pain reduction advantage. However, the difference was not statistically significant because of the small trial.

Haas w Peterson et al. (2007) Dose-response of spinal manipulation for cervicogenic headache: short –term outcomes from a randomised trail, Abstract in Proceedings of the WFC’s 9th Biennial Congress, 161-162

If your head hurts on a regular basis, and you suffer from headaches continually, especially if the pain seems to radiate from your spine or upper shoulder area, this may be a sign of cervicogenic headache. This is especially true is you have suffered trauma to your spine or neck such as whiplash or injury. And you should see your Chiropractor, get it diagnosed and sorted and stop complaining.

This is something we definately don't try here at C1 Chiropractic Health Centre. 

Medicine-assisted Manipulation is defined as manipulation of the spine after any type of anaesthesia or analgesia.  The most common form of this is manipulation under anaesthesia (MUA).

 
In the journal of the North American Spine Society there is a comprehensive review of ‘Chronic low-back pain’ and evidence for and against the numerous methods of managing patients with this condition including MUA.

 

Currently there are several influential clinical guidelines about this sort of stuff such as the Ontario Workers’ Safety and Insurance Board of Canada’s guidelines and in Europe the European Back Pain Guidelines which are all available online.  In the UK the British Medical Research council sponsored the BEAM Trial which has shown “convincingly that both manipulation alone and manipulation followed by exercise provide cost-effective additions to best care (for low-back pain patients) in general practice”

 

The editors are critical of what they call a supermarket response to low-back care where patients are offered a range of untested treatments (with over 200 different forms of care available in the USA) and even those with the most evidence, such as chiropractic still have questions that must be asked.  Every year there appeared to be more treatments available with strong and commercial advocates with generally limited scientific evidence. 

 

However, this review is different with each form of management being tackled by another health care expert, so the review of manipulation under anaesthesia is done by chiropractors. 

 

In this review it demonstrated that there was little evidence supporting or refuting the value of MUA – not a single quality RCT and only a few published cases.  The authors conclude that these is insufficient research to make any conclusions and yet the thing still continues – remarkable really

 

These reviews are available on:

www.science-direct.com/science/journal/15299430

click on Vol.8 Issue 1.

 

 “Chronic low-back pain -

The single most expensive cause of pain and disability in working age adults”

The Spine Journal (2008) 8 (1):1-278

 

In the journal of the North American Spine Society there is a comprehensive review of ‘Chronic low-back pain’ and evidence for and against the numerous methods of managing patients with this condition.

 

Currently there are several influential clinical guidelines about this sort of stuff such as the Ontario Workers’ Safety and Insurance Board of Canada’s guidelines and in Europe the European Back Pain Guidelines which are all available online.  In the UK the British Medical Research Council sponsored the BEAM Trial which has shown “convincingly that both manipulation alone and manipulation followed by exercise provide cost-effective additions to best care (for low-back pain patients) in general practice”

 

However this review is different with each form of management being tackled by another health care expert, so the review of manipulation under anaesthesia is done by chiropractors.  The editors are critical of what they call a supermarket response to low-back care where patients are offered a range of untested treatments (with over 200 different forms of care available in the USA) and even those with the most evidence, such as chiropractic still have questions that must be asked.  Every year there appear to be more treatments available with strong and commercial advocates but with generally limited scientific evidence. 

 

This does present a problem because the gold standard would be high-quality randomized controlled trails (RCT) but the cost of conducting these is, as the report states, “beyond the realm of possibility”.  So, we are left using evidence-informed care rather than evidence-based care.  Though there are more randomized controlled trails examining chiropractic care than any other chronic low-back intervention. 

 

The best available evidence today is not materially different from the recommendations in the Practice Guidelines on Acute Low-Back Pain in Adults published in the US by the Agency for Health Care Policy and Research (AHCPR) in 1994.  The reviews support the findings of this work and add that “a reasonable approach to CLBP would include education strategies, exercise, simple analgesics, a brief course of manual therapy in the form of spinal manipulation, mobilization or massage, and possibly acupuncture”.  And, tellingly, that these treatments should be preferred to more complex or invasive approaches.

 

These reviews are available, free, on www.science-direct.com/science/journal/15299430 and click on Vol.8 Issue 1.

 

The one covering chiropractic is really useful.  It has a history of chiropractic, a description of the examination and treatments in practice today and is seen as being an excellent authority for all concerning chiropractic especially referring medical doctors.  A couple of telling lines:

 

“Spinal manipulative therapy (SMT) or spinal mobilization is superior to usual medical care for patient improvement”

 

“For pain reduction “SMT with strengthening exercises is similar to prescription NSAIDs with exercise in both the short-term and long-term”

 

High-dose SMT is superior to low-dose SMT "for pain reduction in the short term”

 

And from the 9 trials where there were patients with chronic and acute low-back pain the evidence was good that:

 

SMT is superior to usual medical care alone

 

SMT/MOB is superior to physical therapy and to home exercise in the long-term

 

Now this is a change from the old approach where it was recognised that chiropractic was effective in treating acute low-back pain as this now demonstrates that chiropractic is effective in treating chronic as well as acute low-back pain.

 

One of the key advantages of SMT over drug and surgery lies in respect to harm.  The review noted that the only likely side effects of SMT are minor, temporary and typically do not interfere with activities of daily living – a major advantage over spinal surgery I'd argue.

What is it?

 

Seen standing upright from the side someone with perfect posture would have an imaginary centre of gravity line running from just in front of their ear hole through the slight bump on the top-middle of their shoulder.  Normally, the centre of gravity of their head is slightly forward of this line so that a very slight muscle tone is required to keep the head looking forward.  This tone may act to prevent sudden uncontrolled movements of the head, or lolling (you will have personal experienced of this if you have ever fallen asleep sitting up where your head will fall forwards and your inactive muscles suddenly crank up into action and you jerk upright again).  

         

What you get in anterior head carriage is the centre of gravity of the head moving a significant distance forward of the correct centre of gravity line.  In some cases I have seen this has been up to 6cm forward of the correct line. 

 

The problem is spectacularly and increasingly prevalent because of what we do in our lives and, I suspect, is set to get worse and worse as the Wii generation grow up.  It is easy to spot, just go and stand next to someone and look to see if their ear hole is forward of the mid-shoulder line.  I suspect you’ll be surprised how prevent it is, in fact I think if you did a statistical analysis of your friends it would be the statistical norm, but still wrong, posture.

 

How does it occur?

 

The key cause is computer use, especially laptops.  Carrying heavy bags or back packs, lazy posture and telly time with little or no exercise also don’t help but it is the eight hours a day for 30 years that really does the trick especially if it starts when you are young – say in your teens.  Computer work keeps you in a static position (usually a forward curved position as well) for long periods of time, which is why getting up and moving around every 15-20 minutes will help.

 

Backpacks also do it by increasing the overall load on the spine as well as by focusing that extra load onto the shoulders, which is where the major muscles that attach to the back of the skull originate, so putting a much larger strain onto the mechanism of anterior head carriage than the weight of the load would indicate.

 

The other place it I have seen it is in young girls who are tall and they are trying to height hide, though this is getting less common as they don’t fret about it as much as they used to. 

 

What’s the problem with it?

 

The way you achieve anterior head carriage is by straightening your cervical spine from C2 to C7 and in some extreme cases I have even seen reverse curving in the neck. 

 

In terms of skeletal problems this means that you are removing the elegant shock absorbing cervical curve and turning the neck into a column which transfers the weight of the head straight down the neck through the discs and the posterior facets leading to disc damage and facet injury.  This also places the cervical facets in an abnormal position which means they are far more likely to sustain injury.  It is rare for a patient to present at the clinic with non-traumatic acute posterior facet syndrome (you know the sort of thing – the “I don’t know what I did but I woke up like this” cricked neck complaint) who has not got significant anterior head carriage.  Also with anterior head carriage the posterior fibres of the disc annulus get stretched which increases the risk of posterior disc rupture, protrusion or bulge and the subsequent events associated with these grim conditions.

 

In neurological terms a straight cervical spine means that your spinal cord, and therefore nearly every nerve in your body, is physically straightened.  Now, nerves are designed to take this stretch as you look down but only for a short time and there are some interesting studies out there showing the changed anatomy of the spinal cord in a chronic anterior head carriage patient.  Stretched nerves have been shown to function less effectively and their axoplasmic flow is reduced.  I don’t suspect that there is a great deal of tolerance built into the human system. 

 

From the perspective of upper cervical care, when your head and neck are no longer in proper alignment to each other, your muscles have to pick up the slack of supporting your head.  This results in a higher muscle tone in your neck and upper back leading to trigger points in the Traps and Lev Scap muscles.  If you think of the force your muscles have to develop to keep your head from pivoting round your low-cervical vertebrae and smashing into your keyboard you can see why your low-cervical vertebrae suffer.  It is similar to the trick of trying to hold a plank up by the thin end – fine when it’s well balanced but once it comes away from the centre of gravity it takes masses of muscle power to keep it there – it’s all to do with levers.  No wonder people have shoulder trigger points that never seem to resolve; the underlying problem hasn’t been resolved and the outcome will remain the same.

 

The result is neck and upper back pain, restricted cervical biomechanics and all the physiological changes that would be associated with an abnormally functioning neck and upper spine. 

 

Now in some people I have seen there are no problems at all but in others there have been a raft of neck pain, headaches, upper body fatigue, sleep disorders and the rest.  And I would be willing to bet that more than a few people have been mistakenly diagnosed with migraine head ache or tension headache who, in reality, have anterior head carriage and tragic cervical biomechanics.

 

Cure

 

Prevention would be good.  Then if that fails adjust the spine to improve the biomechanics, soft tissue work to help the muscles cope and then some cervical spine stretches to combat the anterior head carriage posture adopted at work.

 

Just typing this up is making my neck hurt!

Within parts of India, Africa, the West Indies and Pakistan, baby massage is considered routine. Grandmothers usually begin the ritual which is carried on by the mother. The practice of massage continues throughout the baby's life, from adolescent to adulthood.

The act of massage strengthens the bond between parent and child. One of the first senses developed within the womb is that of touch. However, leaving the comforting environment of the mother's womb and making an entrance into the world can be a traumatic experience; the Osteopathic Center for Children claim that nine out of ten children suffer some form of trauma during the birth. Premature babies in particular require touch to establish a bond between parent and child. Babies who birth quickly or by Cesarean section may be in shock and benefit from touch; the emotional development of a child is heightened by massage.

It is suggested that babies who receive massage have fewer health problems and both sleep and feed better than those babies who do not receive massage.

The Benefits of Baby Massage
• Bonding – massage helps build a bond between parent and child.
• Security – massage helps secure a relationship between parent and child.
• Emotional – a baby who receives massage leads to a more confident, well-balanced and confident adult in later life who will be less inclined to experience emotional and psychological difficulties.
• Skin – as with any massage, the texture and condition of the skin improves, leaving baby with a healthy looking skin; it also improves blood circulation and helps remove waste products from the body's systems.
• Digestive - a massaged baby will suffer from less colic, constipation and diarrhea and will feed better.
• Respiratory – baby massage will lessen coughs, colds and infections of the ear and nasal passages.
• Nervous System – irritability and tantrums are reduced with massage; a calm baby will lead to a calm parent!
• Immune System – massaged babies have stronger immune systems resisting infections and other health problems.
• Joints and Muscles – baby massage leads to more flexible joints and muscles and greater co-ordination of muscular movement.

We are now providing this interesting service at C1 Chiropractic Health Centre and wonderd if anyone has benefitted from it before?

Core stability

A vast amount of rubbish is spouted about core stability by those poorly trained and frankly pretty dim blokes you meet in gyms.  The terms ‘core function’, ‘core strength’, and ‘core stability’ have become chants with no real understanding of what the terms mean – ask one of them to explain the difference between stability and strength and then which of the two is more important and see what a panic this creates.  However, you will, every now and then, meet one of them who has a profound understanding of these concepts and, if this is the case, ‘bind them to you with hoops of steel’. 

 

The guru on all of this is Prof Stuart McGill, whose lectures and books we have devoured, and I would argue that he is the leading researcher in the world on low back stability. He talks about the following:

The Unstable Spine
To explain how injuries occur to the low-back from such apparently easy tasks as bending over to pick a pencil up off the floor he uses the concept of the unstable spine.  It is worth having in your mind the idea that bending over puts a fairly high load through your low-back; think of it as similar to lifting a plank up by the thin end.  His spectacular and spectacularly painful research shows that these daily tasks can cause your spine to ‘buckle’ if the spine isn’t working well or is unstable.  This buckling can lead to tissue irritation and injury. What causes this to happen is a momentary dip in neural activation of some of the deep intervetebral muscles, leading to a slight rotation in one of the spinal segments.  His solution to this is to train the deep muscles to “stiffen the spine against buckling” and improve its stability. 

 

The Stable Spine
The vertebral bodies have to be able to move and they are brilliantly made to rotate in the sagital, frontal and horizontal plane, as well move along the three axes of these planes.  Of course all joints have an inherent ‘joint stiffness’ because of the bony architecture, passive joint capsules and surrounding ligaments.  Additionally, the muscles are able to control stability of these joints by coordinated muscle coactiviation.  So, for us the task of creating a stable spine is testing but the pattern is there and we are rarely working with nothing.  The goal is to deliver ‘sufficient stability’ which directly relates to optimal stability and mobility with no compromise to the spine. This can be done with exercises that provide coactivation of the deep intrinsic spinal muscles and abdominal wall (transverse abdominis) muscles.

The Main Lumbar Spine Stabilizers
Prof McGill used deep intramuscular electrodes (told you it was painful – but he did do it on himself) to identify the functional roles of the significant spinal stabilizer muscles. He also produced some mathematical models of spinal muscular activity and some amazing computer models to find the key muscles.  He suggests that the important intrinsic muscles of the spine include the multifidus, quadradus lumborum, longissimus, iliocostalis and the transverse abdominins.  Some gym staff surprises there – no rectus abdominis there so the six-pack may only be for decoration.

The Low Back Training Program
From McGill’s research on low-back stability, the data suggest that the healthiest training for the spinal flexors involves muscular endurance not strength training. He adds that “the safest and mechanically most justifiable approach to enhancing lumbar stability through exercise entails a philosophical approach consistent with endurance, not strength; that ensures a neutral spine posture when under load (or more specifically avoids end range positions) and that encourages abdominal muscle co-contraction and bracing in a functional way.”  Bracing can be understood as if the muscles are guy ropes for tent poles as it is a neurophysiological phenomenon involving co-contraction of the abdominal wall and deep intrinsic muscles of the spine in an effort to better stabilize the low back.  

Flexion-Extension “Cat-Camel” Warm-up
He recommends beginning with about six flexion-extension cycles of the “cat-camel” exercise. But he adds that these are done as a mobility exercise to reduce any present stresses on the spine, not as a stretch.  These are shown really well on:

http://www.ccohs.ca/oshanswers/psychosocial/backexercises.html

(and you can see the Prof’s fingerprints all over this one.)

Quadratus Lumborum Training
For quadratus lumborum training he recommends the horizontal isometric side bridge (stick that in Google images and you’ll see what we mean) which can be done from a knee supporting position on the floor or a more testing version which utilizes a feet supported version.  Another advanced version that involves the maximal involvement of the quadratus lumborum and obliques, with co-contraction of the critical spine muscles and transverse abdominis, is the rolling side bridge.

Rectus Abdominis, Obliques, and Transverse Abdominis Training
Prof McGill states that there is no single abdominal exercise that effectively challenges all of the abdominal musculature. He recommends several versions of crunches for the rectus abdominis and obliques.  Pleasingly, he suggests avoiding sit-ups (with bent or straight legs) due to the high psoas muscles activation and the compressive loads this causes in the low-back. Similarly, leg raises also cause a great deal of psoas muscles activation and lumbar spine compression.

Back Extensor Training
Front lying (prone) upper torso (or leg) lifts off the floor may not be wise for people with low-back pain as these may place to much load on the spine. In this exercise the lumbar spine pays a very high compression penalty to a hyperextended spine (approximately 4000 to 6000 N) which transfers load to the facet joints and crushes the interspinous ligament.  This exercise is certainly contraindicated for anyone at risk of low-back injury or re-injury due to the high spine loads and the extended posture. In my opinion it should not be prescribed at all.

 

 

The alternative exercise Prof McGill recommends is the “Bird-Dog” exercise or sometimes in the UK ‘supermen’. This exercise adequately engages the longissimus, iliocostalis, and mutifidus muscles of the spine, with much less stress to the spinal segments.  Again a great site for a few pictures is: http://www.ccohs.ca/oshanswers/psychosocial/backexercises.html

 

McGill, S. M. (2001). Low Back Stability: From Formal Description to Issues for Performance and Rehabilitation. Exercise and Sport Science Reviews. 29, 26-31

 

 

The great problem with adhesive capsulitis (a.k.a. frozen shoulder) is that there is no standard agreed treatment for it. Now the reason for this, I suspect, is because there is no really good understanding of cause – signs and symptoms yes, but cause, no. Therefore addressing the underlying problem becomes a real issue: if there is no understood cause to tackle then curing it is always going to be difficult. So loads of stuff is written about treating the symptoms – which itself has value and several approaches have been advocated (have a look on the internet and see how many options are open to you). However, there have only been a few good research studies on AC and they only looked at a few of the options available. (And here’s a thought, a lack of fully rounded research into complementary care is explainable as it would be hard to gather enough cases to conduct a study. This is unfortunate but reasonable especially taking into consideration how ‘conservative’ many of these procedures are. Cutting your shoulder ligaments apart or sticking some serious drugs into your joints similarly suffers from a paucity of research which is a little strange considering how un-conservative the treatments are – how did they get away with that one I wonder).
When assessing the claims of some available treatments remember that the condition will fully recover on its own even without any treatment whatsoever. So, bearing this in mind, surely the aim of treatment is either to relieve pain while nature gets on with resolving the underlying problem or to speed up the recovery process and both if at all possible. So then choose a therapy which:
1. Reduces pain.
2. Accelerates healing
3. Causes no further damage

So what do we choose?

Painkillers – well, yes they clearly have there place but let’s call them what they really are Painmaskers as ‘killers’ is a marketing deceit designed to give us the impression that the pain has gone (and therefore you are mended) when actually the structures are just as damaged and likely to get worse as you abuse them thinking you are fine.

Injections – have a place but here’s a bit I found on the web:
“Repeated cortisone injections are not healthy for tissues. Small amounts of cortisone in the body are probably reasonable, but repeated injections can cause damage to tissues over time. Sometimes this is of little concern. For example, if a patient has severe knee arthritis, and a cortisone injection every 6 months helps significantly, then the number of injections probably does not matter too much. On the other hand, if a patient has shoulder tendonitis, but an otherwise healthy shoulder, the number of injections should probably be limited to prevent further damage to these tendons.” Did you notice the word damage to tissues – what! How on earth can that be anything but wrong – it’s like saying collateral damage is good. Madness. Try anything before going here as I suspect you are going to need those damaged structures to work in the future.

Massage therapy – done well is certainly the first step. We at C1 Chiropractic Health Centre advocate this alongside some chiropractic manipulation of the neck (C5 dermatome stuff).

Acupuncture – I think so but I’ll let others comment on this.

Surgery - Please don't be tempted to rush into a surgical treatment option until you have really, really, really explored all the other treatment choices.