Chiropractic case studies

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.

Frozen shoulder – what’s that all about?

We’ve seen a few of these lately at C1 Chiropractic Health Centre and we’ve come to see that a whole lot of madness is spouted on about them. Most irritatingly the term is wildly misused and so any painful shoulder with any loss of movement is labelled as a ‘frozen shoulder’. So, let’s start by calling it what it really is: adhesive capsulitis.

What is adhesive capsulitis?
‘Frozen shoulder’ is nearly a slang term - not as bad lumbago but getting close, and refers to loss of arm movement in the shoulder joint with inflammation of the connective tissue of the joint capsule surrounding the shoulder joint. These connective tissues protect the joint, they stabilize the joint and they control a large part of the range of motion of the joint. In an adhesive capsulitis they become inflamed, thickened, shortened and eventually bind together, hence the medical term - adhesive capsulitis which sort of says what it is on the tin.
It affects about two percent of the general adult population. It is most likely to occur in people between the ages of 40 and 60. At present I don’t think that there is any data to suggest that any gender, occupation, or arm domination is more predominant in those who suffer from it. However, diabetic individuals do have an increased risk of developing frozen shoulder. The key point here is the missing bit – the why does it occur and I think this is the strange and interesting part of the problem. We (and I don’t just mean us at the clinic) have no real idea what causes it.

What does it feel like?
Adhesive capsulitis often starts after some minor trauma, dislocation, prolonged immobilisation, heart attack (myocardial infarction) or neck problems (cervical radiculitis). It kicks off with a progressive limitation of shoulder motion which may or may not be painful. However, if you try to push the limited range of motion boundary you will feel pain. This stage is sometimes called the 'freezing' stage. The condition then progresses until all movement is reduced, or to the ‘frozen' stage. Surprisingly, at this point it is common to have no pain. However, this all reversed during the recovery phase and it gets painful again but this will abate when movement is finally restored. This recovery period varies depending on how long the problem has been there and the severity of it.

What can we do to help?
Chiropractic is an effective treatment option for frozen shoulder because it focuses, not on the symptoms, but on the root of the problem. I have yet to meet a patient with AC who has not got some significant neck problems and this may well signpost the way to the elusive underlying cause. However, the most crucial way that chiropractic helps frozen shoulder is in prevention
If it has started then early diagnosis is vital because the condition can be reversed. AC needs more than just chiropractic and we use a mix of chiropractic and sports injury therapy at the clinic and this treatment is very effective.
One thing that seems to work really well with AC patients is having them lie on their back with bad arm in external rotation holding a weight with a hot pack on the shoulder for about 15 minutes. They all seem to get the range of motion back faster with this added to the treatment plan.