Optum health insurance just provided us with a link to a newly published study demonstrating chiropractic safety. This is the second major study demonstrating no evidence of chiropractic causing strokes.

The Conclusion: "In contrast to several other case–control studies, we found no significant association between exposure to chiropractic care and the risk of VBA stroke."

Chiropractic care and the risk of vertebrobasilar stroke: results of a case–control study in U.S. commercial and Medicare Advantage populations
Thomas M Kosloff, David Elton, Jiang Tao and Wade M Bannister

June 13 is Annual Survivor Day! 

You can go to a free 4-hour seminar at locations all over central Virginia. You'll get a free survivor kit at the end!

Dr Gregory went to one of the seminars and found it to be very useful! You'll learn about:

- Basic emergency preparedness
- Food and water safety
- First aid
- Daily personal safety and security

To attend and learn more, register online at www.survivorday.com!

Why, as a sports and rehabilitation chiropractor, do I see so many patients with low back and hip to ankle pain who also have irritable bowel syndrome?

When people have abdominal pain from IBS, celiac, Crohn’s, colitis, ileitis or other inflammatory conditions it inhibits their abdominal muscles and creates an ongoing imbalance that lasts as long as the abdominal pain.  This means that these patients must always work to correct the on the ongoing muscle imbalances or suffer the consequences of overstressed posture.

The added ongoing musculoskeletal stress is especially hard on fibromyalgia patients.

In "The relationship between incontinence, breathing disorders, gastrointestinal symptoms and back pain in women: a longitudinal cohort study",  Smith et al  point out that developing any of these problems increases the likelihood of developing another.

When we work with spinal stabilization we consider and rehabilitate the diaphragm and pelvic floor muscles as major stabilizing components.  If you are not breathing right you are not stable.  This has been a Yoga standard for a couple thousand years.  Pelvic floor weakness is also associated with incontinence and multiple other problems.

Early in my chiropractic practice I noticed a large number of my chronic patients had irritable bowel syndrome, particularly those who also had fibromyalgia.

In 1988 I read a chapter by Vladamere Janda explaining what he named the lower crossed syndrome.  It is a muscle imbalance where your hip flexors (psoas and rectus femoris) are tight and short which inhibits or weakens the hip extensors, your glutes.  This forces your low back extensors to become overly tight to keep you upright.  This inhibits the opposite muscles, the abdominals which are flexors.  

Low back pain automatically inhibits your abdominals responsible for stabilizing your low back.  This causes your main hip flexor, the psoas muscle, to attempt to stabilize and shorten, which inhibits your abs.  Thus low back pain causes lower crossed syndrome as well which, in turn, can cause low back pain and is therefore self perpetuating.

If we sit a lot (on the job, driving or watching TV), our hip flexors become short and cause the same imbalance.

Lower crossed syndrome spreads.  The inhibited glutes permit the hip to internally rotate with each step, particularly when going down stairs.  When the hip rotates in, the knee collapses internally (medially) and the knee cap (patella) is pulled laterally by a retinaculum attached to the IT band.  This causes the knee cap to track poorly and wear out its cartillage.  Occasionally surgeons will perform a lateral release, cutting the retinaculum, which can help the patellar tracking but not the medial collapse which still pulls it off  track.  The IT band also pulls the tibia laterally and rotates it out along with the foot as the hip rotates in.  When the foot rotates out it pronates and the arch falls, stretching the plantar fascia which can become very painful.  The added torque pushes the bog toe across and increases the shearing forces at its base which produces bunions. 

Lower crossed syndrome is one of the main muscle imbalance mechanisms I see contribute to IBS. When treating patients with this issue, and other pelvic pain problems, I help them improve their posture, pelvic floor strength, and abdominal strength. As the patients improve their posture, they reduce the stress on their musculoskeletal system, which improves their bowel health as well.

Image courtesy of Ohmega1982 at FreeDigitalPhotos.net

May is posture awareness month, and we want to do our part by helping our patients understand the risks of bad posture and help them improve!

Because of the extent most of us are on computers and mobile devices, I’d like to provide some resources that will help you develop good ergonomics while on your electronics.



UVA Environmental Health and Safety
This is a great website for information and help! Pay special attention to their list of exercises for computer users, stretch breaks, and their treatise on sitting versus standing at a computer desk.

OSHA Computer Workstation eTool
This will give you great tips to improve your workstation. It helps you identify problems in your current workplace and suggests methods and resources for improvement. Go here for great pictures and guidance!

CU Ergo
The Cornell Human Factors and Ergonomics Research Group has a bunch of guides for workplaces. They are also a good resource for recent research literature.

PhysioAdvisor.com has a good post explaining the risks to your posture while using mobile devices, and provides some tips on how to reduce your risk.


Now that you've learned new techniques to help you maintain good posture while on a computer and mobile device, take part in Posture Month -  come into the office for your posture analysis!

Strength and fitness:

Regular exercise programs help with hypermobility and chronic pain problems such as fibromyalgia, osteoarthritis and rheumatoid arthritis.

With hypermobility syndrome it's important to develop and maintain a good fitness program matching your individual needs. This should to take into account your tissue strength and ability to withstand acute and repetitive stress without sprains, strains, tendinitis or bursitis.

If you fall into one of the more severe categories, you have to consider your vascular strength which may include risk factors for cerebral and aortic aneurysm. Talk to your primary care physician regarding this.

Contact sports or any high impact activity can be damaging. At the same time you want to maximize the strength of your tissues from muscles and tendons to ligaments and bones density. Cardiovascular health needs to be included as well. 

The program should be consistently followed to avoid back sliding and becoming discouraged as well as the difficulty and pain of restarting.

Developing proprioception (body awareness), balance, and reaction timing is critical for prevention of acute injuries and repetitive stress caused by poor coordination.  Maintaining balance and control is important beyond simply not falling down and hurting yourself. This is where exercises such as tai chi and yoga can play a big part – not in training you to stretch further and cross your legs and a weird fashion, but to stand on one foot and remain in control as you shift your weight to the side or to the front. The more hypermobile you are the less proprioceptive input you have regarding your position in the world. If your position sense is not good it's easy to overstress joints. If you're not stable standing on one foot and your ankle is wobbling back and forth you have to ask, what is happening when you're walking?

Overstretching, as in some forms of yoga and weightlifting, frequently produce unwanted symptoms and risk decreasing motor control. Never stretch beyond the range that you would normally use.

Isometric exercise avoids hyperextension and some overuse issues while contributing to strength.

Try to use free weights, body weight and closed chain exercises as opposed to machines when possible. Choosing dumbbells rather than machines in the gym prepares you better for everyday life since they are like real objects and promote better control and stabilization. Use of low impact elliptical training machines can replace high-impact running.

Running a 5K may be a reasonable option for some whereas half marathons are probably a bad idea for anyone who is hypermobile. If you choose to run be certain that you can do it with perfect form all the way down from knees to controlling ankle pronation.

Recovery is a critical component of your program. This includes at least eight hours of sleep. It's best to use undulating periodization to maximize the rest intervals so that you aren't exercising the same muscle groups in the same way too frequently.

Exercising in the pool is a reasonable recovery option but you have to keep in mind that we operate on dry land most of the time and need to maintain competence there. It is also difficult to maintain weight using only pool exercise. Pain-free swimming may require a kickboard or extra care to avoid hyperextending elbow and other joints.  Rotator cuff strength and scapular control are critical.

Lifestyle and ergonomic modification:

You need to protect yourself from impacts, move well, maintain excellent posture and be supported well by your furniture. Things that don't bother other people may bother you and things that don't feel uncomfortable to you may be very damaging to you.

Typing can reduce pain from writing. Alternating between different types of mice can help reduce wrist stress.

Voice control software or a more ergonomic keyboard can reduce pain from typing.

Bent knees or sitting can reduce pain from standing. Avoid shifting your hips forward into a swaybacked position.

Other treatments:

Chiropractors, massage therapists and physical therapists can be used as needed for specific circumstances.

It is counterintuitive to use treatments intended to increase mobility on a hypermobile person. The problem is you need your muscles to control the position of your joints but when painful they are unable to do a good job of this. Experienced massage therapists can help improve function.

When spinal joints are locked up and painful and you are unable to move properly you compensate and can overstretch other areas. Chiropractors and physical therapists can use gentle techniques including muscle energy techniques and mobilization to assist with this. They can also help you figure out your exercise plan and ergonomics.

A pain psychologist referral can be useful e.g. cognitive-behavioral therapy or other evidence-based care.

I highly recommend the following paper and have included some relevant selections below:

“Joint hypermobility syndrome, alternatively termed Ehlers-Danlos syndrome hypermobility type (JHS/EDS-HT), is likely the most common, though the least recognized heritable connective tissue disorder.” ~ Joint hypermobility syndrome (a.k.a. Ehlers-Danlos Syndrome, Hypermobility Type): an updated critique. Castori M

Frequently hypermobility syndrome is not recognized or is considered unimportant unless a family member has a brain or aortic aneurysm due to congenital collagen weakness. I see quite a few novice runners in the training team who have problems caused by hypermobility – more than would be expected in the general population.  It makes sense since I am looking at a subgroup that has problems.

There is a broad spectrum of hypermobility syndromes ranging from a little more than normal flexibility to named genetic syndromes that weaken multiple systems like Marfan Syndrome and Ehlers-Danlos Syndrome.

The term, “hypermobility syndrome” is old and has been replaced in much of the literature but is still in common use. The terminology is currently too nonspecific, lumping together some high risk systemic collagen problems along with more common situations that require only recognition of lower stress tolerance. 

People with hypermobility syndrome often seek our help for multiple problems. Some examples are:

-          Joint instability causing frequent sprains, muscle strains and overstress, tendinitis and bursitis. 
-          Increased injury by impacts in contact sports or accidents.
-          Fibromyalgia Syndrome (FMS).
-          Joint pain including wrists, shoulders, hips, knees, feet (bunions, pronation)
-          Early-onset degenerative joint disease (DJD) (Osteoarthritis)
-          Early, wide spread spinal disc degeneration
-          Temporomandibular Joint Syndrome (TMJ syndrome)
-          Carpal tunnel syndrome

The more severe conditions warrant monitoring the patient for vascular problems.  They also require chiropractors and PTs to be more selective and gentle with manipulation / mobilization, stretching and exercises. It generally takes more effort to develop an effective treatment program and more work and time on the patient’s part to manage the situation.

Your brain and spinal cord know where all your parts are and how they are moving by way of sensory input.  Much of this is from stretch sensation which is diminished in very flexible people. If your central nervous system does not know your joint and body position instantly and there is a delay due to increased stretching, it can move farther before reacting.  This increases damage during impact and also during walking and running.  It forces your muscles to tighten on both sides of a joint during motion to stiffen it and provide information.  This creates tight sore muscles and tendinitis or bursitis. These muscles and tendons as well as ligaments and joint capsules can overstretch as well, which promotes further displacement especially in the ankle and foot.

Diagnosing HMS

I test single leg standing on almost all of my patients.  Their ability to balance with minimal ankle wobbling is important.  When I test patients with eyes closed and, in the extreme, with their head tilted back, they are prevented from relying on vision or inner ear for balance.  They are then forced to rely on information from their foot and the rest of their body to determine where they are and maintain balance.  Eyes closed is a good reflection of how stable you are with the lights off or when texting while standing or walking.

I look at their posture for knees that go backward (Genu recurvatum) and elbows that hyper extend or thumbs that can easily reach their wrist.  Excessive ankle pronation with arch flattening and bunions is an indication of overstretch and excessive shearing motion at the big toe.  These are indications that their collagen is not supporting their structure well.

Female hormones (just before their period) and to a much greater extent, during later pregnancy, greatly increase mobility.  Pregnant women have run Marathons but the question as to whether it is good for them or the baby remains controversial. Children are often more mobile.  There also seems to be a difference between ethnicities around the world. This needs to be taken into account when determining whether the patient is normal or hypermobile and what activities are appropriate. 

Since July 2000, hypermobility has frequently been diagnosed using the Beighton criteria.  The Beighton criteria incorporate the Beighton score along with other symptoms.

The Beighton score: Add 1 point for each of the following:
-          Placing flat hands on the floor with straight legs
-          Left knee bending backward (passive knee hyperextension over 10°)
-          Right knee bending backward (passive knee hyperextension over 10°)
-          Left elbow bending backward (passive hyperextension of the elbows over 10°)
-          Right elbow bending backward (passive hyperextension of the elbows over 10°)
-          Left thumb touching the forearm (passive flexion of the thumbs to the flexor surface of the forearms)
-          Right thumb touching the forearm (passive flexion of the thumbs to the flexor surface of the forearms)
-          Left little finger bending backward past 90 degrees (Passive dorsiflexion of the fifth finger of the hands over 90)
-          Right little finger bending backward past 90 degrees (Passive dorsiflexion of the fifth finger of the hands over 90)

HMS is diagnosed in the presence of two major criteria, one major and two minor criteria, or four minor criteria. The Beighton criteria have not been very well supported in the literature in that the minor criteria do not add much to the correlations.

Major criteria:
-          A Beighton score of 4/9 or more (either current or historic)
-          Arthralgia in four or more joints for more than three months.
-          Criteria major 1 and minor 1 are mutually exclusive as are major 2 and minor 2.

Minor criteria
-          A Beighton score of 1, 2 or 3/9 (0, 1, 2 or 3 if aged 50+)
-          Arthralgia (> 3 months) in one to three joints or back pain (> 3 months), spondylosis, spondylolisthesis/lysis.
-          Dislocation/subluxation in more than one joint, or in one joint on more than one occasion.
-          Soft tissue rheumtism. > 3 lesions  (eg. Epicondylitis, Tenosynovitis, Bursitis)
-          Marfanoid  habitus (tall, slim, span/height ratio >1.03, upper: lower segment ratio less than 0.89, arachnodactyly; positive Steinberg thumb / Walker wrist signs).
-          Abnormal skin: striae, hyperextensibility, thin skin, papyraceous scarring.
-          Eye signs: drooping eyelids, myopia or antimongoloid slant (Palpebral slant)
-          Varicose veins or hernia or uterine/rectal prolapse.


Check back tomorrow for part two: Managing HMS

Image courtesy of Ambro at FreeDigitalPhotos.net

We know some measures that can be taken to protect runners from excessive eccentric loading.

When running downhill, keep your stride short and avoid excessive heel strike. This protects your anterior tibialis which is keeping your toes from slapping down as well as protecting your quadriceps, psoas, and gluteus medius that are stabilizing and controlling your speed.

When you are fatigued to the point that you cannot train with good form any longer, it is time to quit because you're treating compensation instead of good form. You are also increasing stress that will cause you to have to recover longer before you can train again.

At the end of a long training run your hamstrings are fatigued and not decelerating your leg when it swings forward. This increases your stride length, causing heel strike. At the same time you're glutes are fatiguing and not controlling hip sway which is then controlled eccentrically by the TFL - IT. Your glutes are external rotators and when they are fatigued the deep external rotators such as the piriformis have to become overactive to compensate.

Look at the attached study if you are interested in further information. I have edited and reorganized the paper to make it more readable. The paper in its entirety is available for free on pub med. See appendix A at the end of the paper for their walk run program.

I like this paper because they attempt to find cues that were effective in changing behavior rather than simply stating an analysis which as we know frequently does not change what is performed. The fact that this group of subjects had this particular problem is a good indication that they probably have running form issues that are either causative or at least contributory. We do see this problem and problems with similar mechanisms a lot in our novice runners.

Image courtesy of stockimages at FreeDigitalPhotos.net

The staff of Richmond Chiropractic Solutions will be volunteering with Virginia Supportive Housing on February 21. We would love it if you would join us! Please RSVP at least 5 days before the event by replying to this email or calling (804) 288-0582.

Event details:
What: Painting the VSH office
When: February 21, 2015, 1:30 - 5 PM
Where: 5008 Monument Ave
Who: Dr Gregory, Tania, Michael, and our patients!
Why: find our more about the great work VSH does in Richmond at their website: www.virginiasupportivehousing.org/

Sprain your ankle playing sports? Strain your wrist in a throw?  It’s likely you will be told to RICE your injury by your coach, your well meaning neighbor, or your physician (and no, that’s not a reference to the grain grown in waterlogged fields in central and eastern asia).

RICE, which stands for Rest, Ice, Compression, and Elevation, is the go-to formula for treating acute inflammation following a muscle, ligament, or tendon strain. Its goal is to reduce pain and swelling during the initial stage of recovery and prevent further injury. The benefits of RICE are that it’s easy to self-administer at home, generally applicable to most injuries, and doesn’t require in-depth medical knowledge or expensive materials. You can use a variation of the formula when treating anything from a sprained ankle to a biceps strain or a stressed wrist.

However, while there is logical reasoning behind each stage of the RICE formula, clinical research supporting its benefits is not well established.  Because of the number of variables involved in acute strains and sprains (severity, ligaments damaged, condition of the patient, etc) it has been difficult to for researchers to put together a conclusive study (This is not uncommon for many musculoskeletal situations - the people and the injuries are so complex as to make research difficult).  However, one study of looking at ankle sprains in adults gives us a small view into how RICE application actually works. (link study)

The logic is thus:

• Rest both reduces the demands of the afflicted tissue (reducing blood flow and swelling) and helps to avoid stress on already injured tissues
  
  
• Ice reduces swelling by lowering the energy demand of the localized area and contracting blood vessels to decrease blood flow. It also reduces pain by numbing the nerves in the stressed area.
  
  
• Compression stops the internal bleeding from damaged capillaries and helps reduce swelling.
  
  
• Elevation lowers the blood pressure in the area to limit bleeding and increase drainage. 
  

In practice, each aspect of the formula has some qualifiers that need to be addressed. As for most injuries, treatment needs to be modified for the individual and the injury in question. Also, the greatest benefit from all of these would be when implemented immediately.

Of all the steps in RICE, Rest requires the most modification. Research shows that while some rest is good for a sprained joint, exercise and manipulation help to improve muscle strains. Too much rest can become an issue if the joint is kept immobile and the muscle tone starts to degrade. The goal of resting an injured limb is to protect the stressed joint in order for rehabilitation. We want to avoid over-activity and reduce risk of further injury by a poorly performing limb, but we don’t want to increase the recovery time by losing strength and stability from prolonged immobilization. Instead of simple rest, we advocate for Protection with early activation. This can include rest, but also involves protected movement such as bracing, the use of a crutch, aircast, etc. so that graduated controlled motion is added to the recovery plan.

Ice, the next part of the RICE formula, is fairly uncontroversial. Research recommends an icepack (separated from the skin by a thin cloth or towel) or other cooling device placed on the injured joint for 12-20 minute sessions 1-3 times per day. One of the challenges of ice treatment is that it can chill the individual and cause them to tense their strained muscles. If localized ice application gives you the chills, try warming the rest of the body with a heat pack on the stomach to help you relax and enjoy the benefits of cold and heat together.

Compression and Elevation, the final two aspects of RICE, are much harder to research effectively. Their role in initial reduction of swelling by preventing further bleeding is reasonable, and there is no evidence to refute it. However, prolonged use of compression may be unnecessary and we recommend it only for the first day with most injuries. Only in serious muscle contusions and hematomas will the bleeding continue for more than a day and it is important to focus on other aspects of the recovery.

Tennis Elbow. Jumper’s knee. Pitcher’s Shoulder. Repeated actions, such as those performed during many sports, can break down the integrity of a tendon over a period of time. This type of injury is referred to as tendinosis.* 

Unfortunately, the recommended treatment for tendinosis is an exercise regime that often increases soreness in the present. Multiple studies over the past few years have shown that graded eccentric exercises (the lengthening of a muscle under stress) build muscle strength and control in ways that decrease pain and repair tendinosis. However, these types of exercises tend to be more difficult and can increase soreness in the short term.*

Think of the portion of the bicep curl following a lift in which you slowly lower the dumbbell - the eccentric portion of the exercise - and remember the muscle strain.

To ensure that our tendinosis patients aren’t aggravating sore muscles without result, we lay out a recovery plan that is patient and injury specific. We start with a passive approach that breaks down weak tissue and readies it to be replaced with stronger tissue. Then we adjust the biomechanics to decrease the stress on muscles and tendons. We want to ensure correct form so that we do not compound the pain of the injury with bad strength training technique. Next we add in progressive passive to active exercises that include both concentric (muscle contraction) and eccentric (muscle lengthening) exercise. And finally we finish the repair work by polishing off muscle control with eccentric exercises. Of course, after the tendon has been repaired and the muscle strengthened, we will still need to work on regaining the speed and coordination that may have been lost during recovery time.

Remember that exercise routines including eccentric exercise can (and are expected to) flare up symptoms and pain in the short term. As such, tendinosis recovery requires patience and long term focus.

We encourage individuals who are suffering from a long term injury such as tendonisis to consult with a specialist on the specific injury and recovery plan.

Tendinitis, an acute inflammation following tendon or muscle strain, is often confused with tendinosis and requires a very different treatment plan. If you have ever sprained an ankle, it is likely you’ve had tendinitis. However, if you sprain your ankle over and over again you could be developing tendinosis. In next week’s post we’ll address popular and research based treatment for tendintis like sprains and strains (spoiler: the Rest Ice Compression Elevation formula might not be as effective as popular treatment would have us believe).

However, if you have a tendinitis strain that hasn’t recovered (still walking around on that sprained ankle?) or that happens over and over, you may be developing tendinosis, so come see us and we’ll work together on finding a solution.

*Tendinosis can be accompanied by enthesopathies, an exquisitely tender spot on the bone happens when an enthesis (the region in which a tendon meets the bone) has been strained and requires a similar recovery schedule.

Image courtesy of stockimages at FreeDigitalPhotos.net