We all know how important certain aspects in our life are, such as nutrition, exercise and being properly hydrated. Sometimes we overlook a very important component to our over all well being, which is sleep! Not getting into deeper levels of sleep leads to being sleep deprived, which can decrease our physical performance. Being sleep deprived can also worsen conditions such as fibromyalgia, back pain and neck pain. Please review the following article which give us the details about how important sleep is.

Pain Relief updates.

We all know how important certain aspects in our life are, such as nutrition, exercise and being properly hydrated. Sometimes we overlook a very important component to our over all well being, which is sleep! Not getting into deeper levels of sleep leads to being sleep deprived, which can decrease our physical performance. Being sleep deprived can also worsen conditions such as fibromyalgia, back pain and neck pain. Please review the following article which give us the details about how important sleep is.

Lasting pain after a car accident can be debilitating, as an automobile accident lawyer Washington D.C. recommends can tell you. Though the legal process can be frightening, hiring a lawyer you trust can make things easier. The same can be said about getting treatment for your injuries after an accident.

So can a car accident cause Fibromyalgia? What exactly is it?

Those who suffer from it may experience musculoskeletal pain over a large portion of their bodies. It can influence how pain signals in the brain are processed, making painful sensations seem even worse. It can be a deep, throbbing, sharp or dull pain.

You can feel it in your tendons, muscles and ligaments around the joints. Unfortunately, the condition doesn’t have a cure.

Symptoms often start after the body experiences a trauma, with current thinking focusing on head or neck trauma — which can happen because of a car accident. Also, if post traumatic stress disorder also develops, it increases the risk of developing fibromyalgia.

Since there isn’t a cure, treatment is more about managing the symptoms.

How do I know I have it?

Some of the symptoms of Fibromyalgia include:

• Pain in your lower abdomen
• Pain that is more widespread and can may be best described as a dull ache
• Headaches
• Cognitive issues that feel like a brain fog
• Depression or anxiety
• Extreme fatigue, if you find yourself sleeping for long periods of time
• Sleep issues
• Problems with peeing
• Numbness (or tingling) in the arms, hands, feet and legs
• Irritable bowel syndrome

How is it diagnosed?

Diagnosing fibromyalgia isn’t easy. In the past, a tender point exam was used to test 18 points on the body for pain. Now guidelines have been updated to consider a diagnosis after at least three months of medically unexplained pain over a widespread area of the body.

Since there is no real test — and no labs or imaging — in order to diagnose fibromyalgia, it can sometimes go misdiagnosed due to the fact that the main symptoms — widespread joint pain and fatigue — can be somewhat vague.

Treatment can vary, with anti-depressants sometimes being prescribed to help the patient combat fatigue as well as pain relievers to help ease the joint discomfort. It mostly focuses on minimizing the symptoms.

They have also found that anti-seizure medication can lessen some of the pain associated with the chronic condition.

Patients also turn to counseling to learn ways of better coping with the symptoms and deal with the stress and frustrations that come with having the condition.

Sometimes symptoms do not show up immediately after a car accident, so victims should refrain from settling any suits until they know the full extent of their injuries.

If you learn you have developed this after a car accident, you should make sure you have a personal injury lawyer to fight for your interests and hold the other party accountable for your health-related bills. A lifetime of medical care can certainly add up and be overwhelming.

Not only that, because of what the condition does to your energy level, you will more than likely not be able to keep your current job and will suffer a loss in pay.

Thanks to our friends and contributors from Cohen & Cohen, P.C., for their insight into the repercussions of car accidents.

In 1934, William Mixter, MD and Joseph Barr, MD, established that herniation of the lumbar disc could put pressure on the nerve root or the cauda equina, resulting in sciatica. Their paper on the topic appeared in 1934 in the New England Journal of Medicine (1) and was titled:

Rupture of the Intervertebral Disc with Involvement of the Spinal Canal

Dr. Mixter was the primary author of the paper, and at the time, at age 54, he was considered to be the top surgeon in the United States. Dr. Mixter was born in 1880 and graduated from Harvard Medical School in 1906. He became a prominent surgeon at the Massachusetts General Hospital, and by 1911, along with his father, became the primary neurosurgeon at that institution. By the early 1930s, Dr. Mixter was considered to be one of the nation’s leading experts in spinal surgery, and he went on to become the first chief of the neurosurgery department at Massachusetts General Hospital.

This article by Drs. Mixter and Barr fundamentally changed the popular understanding of sciatica at that time, and for this work Dr. Mixter is generally credited by his contemporaries as being the man who best clarified the relation between the intervertebral disc and sciatica. Their landmark article helped to establish surgery’s prominent role in the management of sciatica at the time.

However, this 1934 article by Drs. Mixter and Barr did little to discuss the pathophysiology of low back pain, but rather only discussed the pathophysiology of sciatica. Drs. Mixter and Barr continued to publish studies pertaining to sciatica, and in 1941 they published in the Journal of Bone and Joint Surgery (American) (2) a paper titled:

Posterior Protrusion of the Lumbar Intervertebral Discs

In this article, Drs. Barr and Mixter continue their discussions and case series presentations of posterior lumbar spine disc protrusions and consequent sciatica. Importantly, they also offer perhaps the first explanation for reoccurring low back pain in patients who are not suffering from sciatica. They state:

“A second explanation is that a fissure occurs in the annulus fibrosus as the result of the wear and tear of ordinary use or of degenerative change, and through this fissure there is a slow, gradual extrusion of disc tissue with final resultant symptoms of sciatica when the extruded mass becomes large enough to press upon a nerve root. Clinical cases of this type may have recurring episodes of low backache over many years before the extruded mass becomes large enough to precipitate an attack of sciatica.”

In this paragraph, Drs. Barr and Mixter suggest that “recurring episodes of low backache over many years” may be the consequence of degenerative changes in the annulus fibrosus of the disc accompanied with fissures.

The modern era in the understanding of low back pain began in 1976 when internationally respected orthopedic surgeon, Dr. Alf Nachemson, published his detailed review (136 references) in the journal SPINE (3), titled:

The Lumbar Spine: An Orthopaedic Challenge

In this article, Dr. Nachemson notes that 80% of us will experience low back pain at some time in our life. He further states that:

“The intervertebral disc is most likely the cause of the pain.”

Dr. Nachemson presents 6 lines of reasoning, supported by 17 references, to support his contention that the intervertebral disc is the most likely source of back pain, including the primary research completed by Drs. MJ Smyth and V Wright in

1958 (4). Drs. Smyth and Wright published their paper in the Journal of Bone and Joint Surgery (American), titled:

– Sciatica and the intervertebral disc:
– An experimental study
– Regarding this work by Smyth and Wright, Dr. Nachemson states:

“Investigations have been performed in which thin nylon threads were surgically fastened to various structures and around the nerve root. Three to four weeks after surgery these structures were irritated by pulling on the threads, but pain resembling that which the patient had experienced previously could only be registered only from the outer part of the annulus” of the disc.

In his 1976 review, Dr. Nachemson was noting that a non-herniated disc problem was causing back pain and that the disc itself was a probable source of back pain. Dr. Nachemson notes that the source of back pain must have a nerve supply, but at that time, good studies showing the innervation of the intervertebral disc were lacking.

Support for Dr. Nachemson’s contention of disc pain came in 1981 when Australian clinical anatomist and physician, Dr. Nikoli Bogduk, published an extensive review of the literature on the topic of disc innervation, along with his own primary research, in the prestigious Journal of Anatomy (5). Dr. Bogduk and colleagues conclude:

“The lumbar intervertebral discs are supplied by a variety of nerves.”

and

“Clinically, the concept of ‘disc pain’ is now well accepted.”

In 1983, Dr. Bogduk updates his research when he publishes an article in the journal SPINE titled (6):

The Innervation of the Lumbar Spine

In this 1983 study, Dr. Bogduk states:

“The lumbar intervertebral discs are innervated posteriorly by the sinuvertebral nerves, but laterally by branches of the ventral rami and grey rami communicantes. The posterior longitudinal ligament is innervated by the sinuvertebral nerves and the anterior longitudinal ligament by branches of the grey rami. Lateral and intermediate branches of the lumbar dorsal rami supply the iliocostalis lumborum and longissimus thoracis, respectively. Medial branches supply the multifidus, intertransversarii mediales, interspinales, interspinous ligament, and the lumbar zygapophysial joints.”

“The distribution of the intrinsic nerves of the lumbar vertebral column systematically identifies those structures that are potential sources of primary low-back pain.”

In 1986, Dr. Vert Mooney’s was the president of the International Society for the Study of the Lumbar Spine. That year, his Presidential Address was delivered at the 13th Annual Meeting of the International Society for the Study of the Lumbar Spine, May 29-June 2, 1986, Dallas, Texas. It was published in the journal SPINE in 1987, and titled (7):

Where Is the Pain Coming From?

In this article, Dr. Mooney states:

“Anatomically the motion segment of the back is made up of two synovial joints and a unique relatively avascular tissue found nowhere else in the body – the intervertebral disc. Is it possible for the disc to obey different rules of damage than the rest of the connective tissue of the musculoskeletal system?”

“Persistent pain in the back with referred pain to the leg is largely on the basis of abnormalities within the disc.”

“Mechanical events can be translated into chemical events related to pain.” An important aspect of disc nutrition and health is the mechanical aspects of the disc related to the fluid mechanics.

“Mechanical activity has a great deal to do with the exchange of water and oxygen concentration” in the disc.

The pumping action maintains the nutrition and biomechanical function of the intervertebral disc. Thus, “research substantiates the view that unchanging posture, as a result of constant pressure such as standing, sitting or lying, leads to an interruption of pressure-dependent transfer of liquid. Actually the human intervertebral disc lives because of movement.”

“In summary, what is the answer to the question of where is the pain coming from in the chronic low-back pain patient? I believe its source, ultimately, is in the disc. Basic studies and clinical experience suggest that mechanical therapy is the most rational approach to relief of this painful condition.”

“Prolonged rest and passive physical therapy modalities no longer have a place in the treatment of the chronic problem.”

The model presented by Dr. Mooney in this paper includes:

The intervertebral disc is the primary source of both back pain and referred leg pain. The disc becomes painful because of altered biochemistry, which sensitizes the pain afferents that innervate it. Disc biochemistry is altered because of mechanical problems, especially mechanical problems that reduce disc movement. Therefore, the most rational approach to the treatment of chronic low back pain is mechanical therapy that restores the motion to the joints of the spine, especially to the disc. Prolonged rest is inappropriate management.

Additional support for the disc being the primary source of back pain was presented by Dr. Stephen Kuslich and colleagues in the prestigious journal Orthopedic Clinics of North America in April 1991 (8). The title of their article is:

The Tissue Origin of Low Back Pain and Sciatica:

A Report of Pain Response to Tissue Stimulation During Operations on the Lumbar Spine Using Local Anesthesia

The authors performed 700 lumbar spine operations using only local anesthesia to determine the tissue origin of low back and leg pain, and they present the results on 193 consecutive patients studied prospectively. Several of their important findings include:

“Back pain could be produced by several lumbar tissues, but by far, the most common tissue of origin was the outer layer of the annulus fibrosis.”

The lumbar fascia could be “touched or even cut without anesthesia.”

Any pain derived from muscle pressure was “derived from local vessels and nerves, rather than the muscle bundles themselves.”

“The normal, uncompressed, or unstretched nerve root was completely insensitive to pain.”

“In spite of all that has been written about muscles, fascia, and bone as a source of pain, these tissues are really quite insensitive.”

In summary, Dr. Kuslich and colleagues found that the outer annulus is “the site” of a patient’s back pain. Irritation of a normal or inflamed nerve root never produced low back pain. Back muscles themselves are not a source of back pain; in fact, the muscles, fascia, and bone are really quite insensitive for pain. Also the inflamed, stretched, or compressed nerve root is the cause of buttock, leg pain and sciatica, but not back pain.

In 2006, physician researchers from Japan published in the journal SPINE the results of a sophisticated immunohistochemistry study of the sensory innervation of the human lumbar intervertebral disc (9). The article is titled:

The Degenerated Lumbar Intervertebral Disc is Innervated Primarily by Peptide-Containing Sensory Nerve Fibers in Humans

These authors note:

“Many investigators have reported the existence of sensory nerve fibers in the intervertebral discs of animals and humans, suggesting that the intervertebral disc can be a source of low back pain.” “Both inner and outer layers of the degenerated lumbar intervertebral disc are innervated by pain sensory nerve fibers in humans.”

Pain neuron fibers are found in all human discs that have been removed because they are the source of a patient’s chronic low back pain.

The nerve fibers in the disc, found in this study, “indicates that the disc can be a source of pain sensation.”

The perspective offered by these studies from 30 years of publications and research in the best journals is that the annulus of the intervertebral disc is primarily responsible for the majority of chronic low back pain. Acourding to Dr. Vert Mooney (7) above, the pain producing disc lesion is segmental, or pertaining to abnormal mechanical function of an intersegmental “motion segment of the back.”

Where Does Neck Pain Come From?

In 1993, Australian physician / clinical anatomist Nikioli Bogduk and American physician / radiologist Charles Aprill thoroughly evaluated the tissue sources for chronic neck pain. They published their findings in the journal Pain (10) in an article titled:

On the nature of neck pain, discography and cervical zygapophysial joint blocks

In this study, the authors evaluated the sources of chronic neck pain by using both provocation discography and cervical zygapophysial joint blocks. Their findings include:

“Both a symptomatic disc and a symptomatic zygapophysial joint were identified in the same segment in 41% of the patients.”

“Discs alone were symptomatic in only 20% of the sample.”

“Zygapophysial joints were symptomatic but discs were asymptomatic in 23%.”

“Only 17% of the patients had neither a symptomatic disc nor a symptomatic zygapophysial joint at the segments studied.”

Neck muscle injury “does not provide a satisfying model for persistent or chronic neck pain.”

A summary of the findings of Drs. Bogduk and Aprill from this 1993 study include:

The most frequent finding was “both a symptomatic disc and a symptomatic zygapophysial joint at the same segment,” seen in 41%. There is important clinical relevance to the finding that the primary source of chronic neck pain was segmental, involving both the intervertebral disc and the facet articulation.

The second most frequent finding was a symptomatic zygapophysial joint, alone, with no disc involvement, which was found in 23%.

“This indicated that 64% of the sample had a symptomatic zygapophysial joint.” [41% + 23% = 64%]

The third most frequent finding was a symptomatic disc alone, with no zygapophysial joint involvement, found at 20%.

This indicated that 61% of the sample had a symptomatic disc.

[41% + 20% = 61%]

The most important finding in this study was that the most common source for chronic neck pain was both articular (facet and disc) and segmental.

This 1993 study by Bogduk and Aprill was followed by two studies completed by the Australian research team of Leslie Barnsley, Susan Lord, Barbara Wallis, and Nikioli Bogduk. Both studies were published in the journal SPINE, in 1995 (11) and in 1996 (12). Both studies confirm the conclusions of Aprill and Bogduk from 1993: chronic neck pain is primarily segmental and articular, not muscular.

•••••

A series of experimental studies involving pigs (13, 14), cats (15) and humans (15), all published in the journal SPINE, established that sensory irritation of the nerve fibers found in the intervertebral disc and/or the facet joint capsule will initiate a reflex contraction of the segmental multifidus muscle. This has great clinical significance because the studies reviewed above document that the primary sources of chronic low back and neck pain are sensory irritations to the disc and/or facet joint capsules. Apparently the same sensory irritation causing the perception of pain also initiates a segmental contraction of the mutlifidus, locking the segmental motor unit into a fixed pattern of position and/or movement. In the chiropractic profession, this segmental locking of the motor unit is referred to as a “vertebral subluxation.”

This positive feedback loop between the disc/facet and multifidus contraction, affecting segmental motion, can explain cases of chronic spine pain. The clinical significance of this aberrant neurobiomechanics was recognized in 2006 by Dr. Manohar M. Panjabi. Dr. Panjabi, Ph.D. is from the Department of Orthopaedics and Rehabilitation, Yale University School of Medicine. A search of the National Library of Medicine database using the PubMed search engine (December 2009) showed that Dr. Panjabi is credited with an incredible 265 publications. Dr. Panjabi’s article was published in the European Spine Journal, and titled (16):

A hypothesis of chronic back pain:

Ligament subfailure injuries lead to muscle control dysfunction

In this article, Dr. Panjabi presents an explanation for chronic spinal pain as a consequence of subfailure injuries of ligaments (spinal ligaments, disc annulus and facet capsules) that cause chronic segmental muscle control dysfunction. His treatment approach is to treat the articular (disc and facet) mechanoreceptors. It appears that the positive feedback loop causing chronic segmental muscle control dysfunction can be aborted by improving segmental articular mechanical function.

How Does One Abort

the Positive Feedback Loop of Segmental Dysfunction?

Two studies show that the positive feedback loop of segmental dysfunction can be aborted by the stretching of the facet joint capsules at the level of dysfunction, resulting in the firing of facet joint mechanoreceptors. One study involved pigs, and was published in SPINE in 1997 (14). The other study involved humans, and was published in the New England Journal of Medicine in 1994 (17). In the 1997 study, stretching of the facet joint capsules and firing of the capsular mechanoreceptors aborted the contraction of the multifidus muscle. In the 1994 study, stretching of the facet joint capsules and firing of the capsular mechanoreceptors aborted the patient’s pain complaint. In both studies, the stretching of the facet joint capsules and firing of the capsular mechanoreceptors was accomplished by distending the capsule by the injection of a liquid. The exact words from the 1994 New England Journal of Medicine study were:

“… the patients who derived a benefit from either treatment may have had a condition that was improved by the stretching of the joint capsule during intraarticular injection, irrespective of what was injected.”

Can exercise initiate adequate stretch to the facet joint capsules to fire the mechanoreceptors, abort the multifitus contraction, improve segmental biomechanics and inhibit chronic pain?

Apparently, the answer is “No,” or at least not very well. This does not imply that exercise is without value as an aspect of chronic spinal pain management. Recall from Dr. Kirkaldy-Willis that segmental motion has three ranges (18):

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According to Dr. Kirkaldy-Willis, the limit of anatomical integrity is created by the capsular ligaments of the facet joints. It is the stretching of these capsular ligaments that fires the mechanoreceptors that abort the deleterious positive feedback loop discussed above. Exercise is less effective in affecting the joint capsular ligaments that other approaches.

Is there a method to stretch to the facet joint capsules to fire the mechanoreceptors, abort the multifitus contraction, improve segmental biomechanics and inhibit pain?

Apparently, the answer is “Yes.” As a representative study, in 2002, physical therapist Jan Lucas Hoving published a study in the Annals of Internal Medicine, titled (19):

Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain:

A Randomized, Controlled Trial

In this study, “Manual Therapy” was defined as:

“According to the International Federation of Orthopedic Manipulative Therapies, ‘Orthopedic manipulative (manual) therapy is a specialization within physical therapy and provides comprehensive conservative management for pain and other symptoms of neuro-musculo-articular dysfunction in the spine and extremities.’”

This study involved 183 patients who were followed for a 7-week period. The physical therapy used consisted primarily of active exercise, therapies exercises, postural exercises, and stretching. At 7 weeks, the success rates were 68.3% for manual therapy, 50.8% for physical therapy exercise, and 35.9% for continued physician care. The authors noted:

“The success rates for manual therapy were statistically significantly higher than those for physical therapy [exercise].”

“Manual therapy scored better than physical therapy [exercise] on all outcome measures…”

“Range of motion improved more markedly for those who received manual therapy or physical therapy [exercise] than for those who received continued care.”

“Patients receiving manual therapy had fewer absences from work than patients receiving physical therapy [exercise] or continued [physician] care.”

“Manual therapy and physical therapy [exercise] each resulted in statistically significantly less analgesic use than continued [physician] care.”

“The postulated objective of manual therapy is the restoration of normal joint motion, was achieved, as indicated by the relatively large increase in the range of motion of the cervical spine.”

“In our study, mobilization, the passive component of the manual therapy strategy, formed the main contrast with physical therapy [exercise] or continued care and was considered to be the most effective component.”

These authors concluded:

“In daily practice, manual therapy is a favorable treatment option for patients with neck pain compared with physical therapy or continued care by a general practitioner.”

“Primary care physicians should consider manual therapy when treating patients with neck pain.”

Conclusions

Chronic spine pain is often articular (disc and/or facet) and segmental. Sensory nerves in the disc and/or facet joint capsules can initiate the perception of the pain signal in the brain; and simultaneously initiate a reflex to the segmental multifidus muscle, locking the segmental motor unit into aberrant and adverse positional or movement patterns. These aberrant and adverse positional or movement patterns further stress the disc and/or facet capsule sensory nerves, creating a positive feedback loop. This adverse positive feedback loop can be aborted by the firing of facet joint capsule mechanoreceptors. The firing of the facet joint capsule mechanoreceptors can be safely accomplished with manual/manipulative therapy, improving local biomechanics, pain and disability. Such manual/manipulative therapy requires education, experience, and skill.

References
1) Mixter WJ, Barr JS. Rupture of the Intervertebral Disc with Involvement of the Spinal Canal. New England Journal of Medicine. CCXI, 210, 1934.

2) Barr JS, Mixter WJ. Posterior Protrusion of the Lumbar Intervertebral Discs. Journal of Bone and Joint Surgery (American). 1941;23:444-456.

3) Nachemson AL, The Lumbar Spine: An Orthopaedic Challenge. Spine, Volume 1, Number 1, March 1976, pp. 59-71.

4) Smyth MJ, Wright V, Sciatica and the intervertebral disc. An experimental study. Journal of Bone and Joint Surgery [American];40: 1958, pp. 1401-1408.

5) Bogduk N, Tynan W, Wilson AS. The nerve supply to the human lumbar intervertebral discs, Journal of Anatomy; 1981, 132, 1, pp. 39-56.

6) Bogduk N. The innervation of the lumbar spine. Spine. April 1983;8(3): pp. 286-93.

7) Mooney, V, Where Is the Pain Coming From? Spine, 12(8), 1987, pp. 754-759.

8) Kuslich S, Ulstrom C, Michael C; The Tissue Origin of Low Back Pain and Sciatica: A Report of Pain Response to Tissue Stimulation During Operations on the Lumbar Spine Using Local Anesthesia; Orthopedic Clinics of North America, Vol. 22, No. 2, April 1991, pp.181-7.

9) Ozawa, Tomoyuki MD; Ohtori, Seiji MD; Inoue, Gen MD; Aoki, Yasuchika MD; Moriya, Hideshige MD; Takahashi, Kazuhisa MD; The Degenerated Lumbar Intervertebral Disc is Innervated Primarily by Peptide-Containing Sensory Nerve Fibers in Humans; Spine, Volume 31(21), October 1, 2006, pp. 2418-2422.

10) Bogduk N, Aprill C. On the nature of neck pain, discography and cervical zygapophysial joint blocks; Pain; August 1993;54(2):213-7.

11) Barnsley L, Lord SM, Wallis BJ, Bogduk N. The prevalence of chronic cervical zygapophysial joint pain after whiplash. Spine. 1995 Jan 1;20(1):20-5.

12) Lord SM, Barnsley L, Wallis BJ, Bogduk N. Chronic cervical zygapophysial joint pain after whiplash. A placebo-controlled prevalence study. Spine. 1996 Aug 1;21(15):1737-44.

13) Indahl A, Kaigle A, Reikerås O, Holm S. Electromyographic response of the porcine multifidus musculature after nerve stimulation.Spine. 1995 Dec 15;20(24):2652-8.

14) Indahl A, Kaigle AM, Reikeras O et al (1997) Interaction between the porcine lumbar intervertebral disc, zygapophysial joints, and paraspinal muscles. Spine 22:2834–2840.

15) The ligamento-muscular stabilizing system of the spine. Solomonow M, Zhou BH, Harris M, Lu Y, Baratta RV. Spine. 1998 Dec 1;23(23):2552-62.

16) Panjabi MM. A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction. Eur Spine J. 2006 May;15(5):668-76.

17) Barnsley L, Lord SM, Wallis BJ, Bogduk N. Lack of effect of intraarticular corticosteroids for chronic pain in the cervical zygapophyseal joints. N Engl J Med. 1994 Apr 14;330(15):1047-50.

18) Kirkaldy-Willis, W.H., M.D., & Cassidy, J.D.,”Spinal Manipulation in the Treatment of Low-Back Pain,” Can Fam Physician, (1985), 31:535-40.

19) Hoving JL, Koes BW, de Vet HCW, van der Windt AWM, Assendelft WJJ, van Mameren H, Devillé WLJM, Pool JJM, Scholten RJPM,Bouter LM. Manual Therapy, Physical Therapy, or Continued Care by a General Practitioner for Patients with Neck Pain A Randomized, Controlled Trial. Annals of Internal Medicine, Vol. 136 No. 10, Pages 713-722 May 21, 2002.

When treating athletic injuries, most health care providers do not evaluate the athlete from a structural or functional standpoint. The typical approach when an athlete or patient is injured, is to provide treatment just to remove the symptoms, such as neck pain or back pain, and not figure out the cause. Most high-level athletes have strength and conditioning coaches who teach techniques to address issues such as power, speed, and strength, but a functional evaluation checking for movement inefficiencies is typically not performed. Until an athlete or patient is evaluated by a functional exam, that uncovers abnormal movement patterns, injuries will not be prevented or treated correctly. Ideally, detecting abnormal movement patterns will become common place in sports medicine. When a functional evaluation is combined with a chiropractic exam, unbalanced or abnormal muscle function and areas of muscular and joint dysfunction can be detected and corrected.

Movement efficiency is key to injury prevention, performance enhancement and full recovery from athletic injuries. When we talk about movement efficiency, we are referring to components such as: Balance, Core strength, Dynamic flexibility (being strong and mobile), Functional strength (strength through a full range of motion), Reactive neuromuscular control (proper communication and coordinated movements between the nervous system and muscular system), and normal joint motion.

Some common examples of movement inefficiencies would be an inward buckling of the knee (valgus deformity) and decreased upward movement of the foot (dorsiflexion) with squatting or performing a lunge movement. (1) Another common movement inefficiency is decreased hip internal rotation (inward movement of the femur or thigh) when performing twisting or rotational movements, which causes the low back to be required to turn more to make up for the decreased hip motion. These abnormal movement patterns can result in lower extremity pain and injury as well as back pain and/or injury. These faulty motion patterns can also predispose an athlete to break down and possibly incur an injury if not detected and treated.

An example of a functional evaluation that detects movement inefficiencies and muscular imbalance would be a system developed by Fusionetics. Below is the typical movement patterns performed in a Fusionetics evalution:

The abnormal movement patterns detected by the Fusionetics evaluation are recorded and fed into a database that creates a specific set of corrective exercises. When this type of evaluation is coupled with a chiropractic exam incorporating not only orthopedic and neurological testing, but also evaluating for abnormal joint motion, a complete program of sports medicine rehabilitation can be initiated.

If you would like more information, have questions, or would like to schedule a consultation, you can do so with the online booking feature at www.drmontehessler.com

References:
(1) Am J Sports Med. 2005 Apr;33(4):492-501. Epub 2005 Feb 8.
Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study.

For more information on Sports Medicine, click here.

It’s easy to look at an athlete’s highlight reel and stand in awe of their ability to play. To see the ease of their movements and the way they seem to know exactly what to do at exactly the right moment, it’s like they were born to be in that sport. They were born to be a star.

However, the skills these competitors show on the court or field don’t always tell the complete story says Eddie Johnson, retired NBA star who now commentates for the Phoenix Suns while also running his own business, JJJ Sports, offering basketball camps, clinics, motivational speaking services, and more. “People don’t realize what athletes do behind the scenes,” he says.

Athletes Are Created Off the Court

Johnson knows all too well what it takes to have a successful sports career. In fact, during his 17-year stint (from 1981 to 2000) as a shooting guard and small forward, he scored more than 19,000 points, earning the NBA’s annual “6th Man of the Year” award for averaging 21.5 points per game for the Phoenix Suns with roughly 29 minutes play time.

Though Johnson has undoubtedly put in a lot of time in, working on both his body and his sport, he adds that sports chiropractic has been a consistent part of his fitness regimen. “I’ve always had structural doctors,” he says, further revealing that, while he’s never had any major back issues, he has always had alignment issues. “When you’re working out, your muscles tend to get tight on one side of the body,” he says.

Today, Johnson’s “structural doctor” is Monte Hessler, DC, CCSP, team chiropractor for the Phoenix Suns. We spoke to Hessler, who also happens to be the PGA Tour chiropractor and chiropractic consultant for the San Francisco Giants, and he indicated that there are two basic ways chiropractic can benefit pro athletes. The first is to help the athlete perform at a higher level and the second involves decreasing the likelihood of injury.

Sports Chiropractic Benefit #1: Improving Athletic Performance

“You can do all of this training in strength and skill training to participate in your sport, but sometimes there are what I like to call ‘movement inefficiencies,’” says Hessler. “If we don’t clear out these inefficiencies, it’s like building on an unstable foundation.”

That’s why Hessler’s goal when working with athletes is focus on creating that stable foundation. “Normalizing them from a motion, joint function, and muscular standpoint sets the foundation for them to do the things they need to do,” he says. And it’s been met with positive results.

“I’ve heard repetitively from athletes, players who’ve been adjusted, that they feel like they can focus better,” Hessler says. “Basketball players have said, ‘the ball feels different in my hands after you adjust me.’ If you break it down neurologically, if you have a tight joint or muscle that is putting abnormal sensations into the nervous system and remove it, they can be able to focus.”

In fact, there have been many studies that talk about how proprioception improves after chiro adjustments. For instance, one study published in the Journal of the American Chiropractic Association concluded that “manipulation is an effective modality in the improvement of both proprioception and dorsiflexion in chronic recurrent ankle sprain.”

Another piece of research, this one published in the Journal of Manipulative and Physiological Therapeutics, found that chiropractic and proprioceptive exercises can also help decrease recurrent shoulder instability. And this was after the participant being studied had two previous surgeries which were unsuccessful at correcting that instability.

Sports Chiropractic Benefit #2: Decreased Injury Risk

The second benefit is decreased injury risk. “Poor movement patterns create compensation and muscular imbalance, leading to injury,” adds Hessler. This is a major issue for pro athletes especially since their livelihood is dependent on their ability to play their sport.

Recent stats indicate that this is a problem area, says Hessler, who indicates that some sports, like Major League Baseball, has seen an increase in injuries over the past several years. This is “despite improvements in training, conditioning, diagnostic tools, and surgical intervention,” says Hessler, highlighting this concern even more.

Research has found that chiropractic can help reduce the risk of many different injuries. For example, one study connected chiropractic intervention with lower limb injury prevention, reduced primary lower limb muscle strain, and, subsequently, sports players spending fewer weeks off due to non-contact knee injuries.

To sum it up, “some of the things we provide as DCs are at the base level of improving athletic performance and injury prevention,” says Hessler. And that’s where a strong foundation begins.

DoCS is committed to raising the bar in chiropractic for athletes, so if you have any questions or article ideas, please feel free to contact us or share them in the comment section below. Reprints of this article permitted as long as it links back to the DoCS website: www.DoC-Sports.com.

If you’ve ever been injured, most likely it’s an injury to a joint or muscles surrounding a joint. Besides pain that you feel, your body will contract that joint and the muscles around it.

Why? To protect it. It’s a good thing, for a short time. But far too often the muscles stay stiff and contracted and the joint becomes less mobile and this becomes a chronic problem over time.

The best therapy is to first to take the joint through its complete range of motion. Then, after a few days to weeks, the next thing to do is to begin to strengthen the muscles around the joint. This will improve muscle strength, improve mobility in the joint, and put you on the path of healing.

However, what is not discussed much at all is that for complete healing, not only does the joint need to be taken through its complete range of motion, the muscles need to be strengthened through their complete ranges of motion.

In other words, if you had a compaction injury to a shoulder joint in a car accident (you were hit by another vehicle and your shoulder slammed into the door frame), your shoulder will go through inflammation, contraction, and joint immobility.

After the inflammation is reduced then you go about improving range of motion, increasing strength to the surrounding muscles as I indicated above.

But in addition, you must exercise the joint and muscles through their ENTIRE range of motion. This means; if your shoulder joint goes from zero degrees – in an anatomical posture that is, your hand down by your side – to 180 degrees above your head, you need to exercise all 180 degrees. All the way up, and all the way down – in flexion and extension. Most likely you will have to start out with much smaller degrees of motion and then over time, build up to larger.

You can do exercise the muscles with rubber tubing (I would not recommend free weights because you don’t want more weight than you can handle). Or, you can exercise the muscles in these degrees of motion with a qualified trainer or a rehabilitative professional.

When you exercise the muscles through its entire range of motion you are gaining more effect on the muscles, building more muscle tissue and as important, exercising the joint through its complete range of motion as well. You’ll be stronger, your joints will be more efficient, and in turn, you should not have the chronic problems often associated with joint injuries.

Thanks to our friends and contributors from Myoride Fitness for their insight into healing injuries.

What would you do if you or a loved needed long-term care? Would you be prepared to pay for it? Although most people will need long-term care within their lifetime, most adults do not plan ahead for it. That leaves family members and seniors scrambling for funds to afford care. You can avoid that stress by using these pieces of advice to plan ahead for long-term care.

Make Modification Now to Support Aging in Place

One way that you can better prepare for long-term care is to prepare your home to age in place. You will need to make sure all rooms and spaces are fully accessible, especially if you anticipate reduced mobility. Walkers and wheelchairs can make maneuvering through your home a bit trickier, so if you can, have doorways widened.

Undoubtedly, your accessibility upgrades will include some products to make it safer and more secure as well. Consumers Advocate provides detailed information about home-upgrade solutions, such as walk-in showers, chair lifts, and medical alert devices, that can keep seniors protected as they age in place in their own homes.

Plus, making these changes now will make it less likely that you will suffer a serious fall in the future. Injuries from falls can be debilitating for older adults and can bring about the need for long-term care, so taking proper precautions is prudent. Install grab bars in the bathroom and slip-resistant flooring to maintain your independence.

Plan for Practical Ways to Pay for Long-Term Care

Like many seniors, you may be planning on relying on Medicare for your health needs. But Medicare will not help with the costs of long-term care in the majority of cases. The most Medicare may pay for is 20 days at a skilled nursing facility. Since most long-term needs extend beyond this narrow window, your best bet is to be prepared to cover those long-term care expenses.

Home health assistants are the most economical long-term care option, but if you or a loved one needs to be in a nursing home, that bill can run upward of $100K per year. That’s a huge expense for seniors and family members to budget for on the fly, which is why it is important to plan ahead for other long-term care solutions. Some people do end up paying out of pocket, from either their savings or retirement funds, but you can also find help paying for that essential care. Veterans can get assistance from the VA, and you may even be able to lock in some affordable rates for long-term care insurance, if you purchase your plan early enough.

Start Taking Better Care of Your Overall Health

If you can take steps to prepare your home for long-term care needs, then you can also prepare yourself. Making healthier lifestyle choices is your best defense against needing extensive care in the first place, so make an effort to take better care of your health. Again, fall prevention is critical, and you can take steps to strengthen your body against potential injuries. Exercise is a definite health necessity, and getting more of it can build more stable muscles and joints that can keep you upright.

You can also add supplements to your diet to boost your physical health, or try adding healthier foods to keep your body and brain strong. Fish is high on that list, but you can also get benefits from eating more blueberries and nuts and possibly from drinking coffee as well. Finally, top off those healthy new habits by refining your sleep hygiene. Sleep is central to your cognitive health and immune system, so getting more of it can help you retain more control over your life.

Many seniors forget to think about their need for long-term care until it’s too late. You can avoid that added stress for yourself and loved ones by planning ahead to preserve your health, prepare your home, and prime your finances for the high costs of long-term care.

When athletes are faced with an injury, the effects can potentially extend beyond those that are physical in nature. Sometimes they take a toll mentally as well.

Depending on the athlete and the nature or extent of the injury, these mental reactions to injury can include changes in appetite, sleep issues, irritability, depression, a lack of motivation, and even alienation according to a statement published by the American Academy of Orthopaedic Surgeons.

And if they’re excessive, anger and rage may appear, causing the athlete to experience emotional outbursts or have greater struggles with substance abuse issues.

What can you do to help athletes avoid these types of responses and keep pushing forward? Here are tips provided by nine pro sports DCs that work to help their injured athletes stay in the game mentally.

Really Listen to Their Concerns

“I think one of the most important things we as providers can do is listen,” says Jay Greenstein, DC, CCSP, CKTP, CGFI, team provider for the NFL’s Washington Redskins Cheerleaders. “If you are truly listening to what the athlete is saying and evaluating how they’re saying it, you can understand what their true needs are.”

With this, Greenstein stresses that there is always a balance between asking too much and getting to the heart of the matter. There is also an obligation to keep the athletic trainer in the loop. However, if you are authentically curious and really listen to what your athletes have to say, they’re more inclined to trust you. “It’s really about empathy,” Greenstein says.

Help Them See Their Injury for What It Is

“For young athletes, I remind them that what they do today for their body will determine the longevity of their careers,” says Sabrina Atkins, DC, team chiropractor for the NBA’s Orlando Magic and Orlando Ballet. “For the older and more seasoned athletes, there is a gentle reminder that the recovery process takes a little longer,” says Atkins.

Taking this approach helps the athlete become more reassured that they’re “doing the right thing by taking care of the injury and letting it heal,” Atkins says. To help them understand better, she reminds them what it was like when they first got into their sport, the amount of time and energy it took to achieve a level of proficiency and confidence. That’s what will happen with this injury too.

Inform Them the Injury Can Actually Help Them Build Strength

“I talk to them about using the injury as a way to strengthen not only the area that is injured, but everything else,” says Jason T. Levy, DC, ART, CCSP, CKTP, team chiropractor for the New York Jets (NFL), New Jersey Devils (NHL), and New York Red Bulls (MLS). For instance, Levy shares treats a high-level triathlete who blew out her ACL.Yet, after rehabbing, she is way ahead of where she should be.

This is an issue Levy says that he sees in elite athletes, where they are weak in certain areas, but compensate to make up for it. However, rehabbing from an injury gets them to build up those areas instead and, “a lot of times, they come back better than ever,” he says.

Help Them Tap Into Their Personal Power

Another approach that Monte Hessler, DC, CCSP, says works well is helping athletes tap back into the power they felt when they weren’t injured. “It’s important to visualize and feel what it was like when they were at their best,” says Hessler, who is team chiropractor for the Phoenix Suns, PGA Tour chiropractor, and chiropractic consultant for the San Francisco Giants

“It helps if the athlete recalls all of the sensory feelings they had when they were at the top of their game and having fun,” Hessler says. So, he helps remind them how it felt to make that perfect play, who they were with, where they were at the time, and any other details they can recall using the five senses to make those visualizations more real.

Encourage a Focus on Recovery

“Dealing with an unexpected injury can certainly be a challenge to any athlete’s identity whether high school or professional,” says Karen Slota, BS, DC, team chiropractor for the Detroit Lions. “My goal when dealing with athletes and their injuries is to shift their focus away from what they can’t control and towards something they can control – their recovery.”

This involves getting them to concentrate on things like managing inflammation, soft tissue recovery, restoring strength, and improving flexibility. “Luckily for many of my athletes, we have the ability to work with a great team of professionals that all provide their expertise in these areas to reinforce the path of recovery for the athlete,” Slota says.

Remind Them They Aren’t Alone

“Most professional athletes have been on a consistent training program since they were very young,” says Mary Collings, DC, team chiropractor for the NHL’s Dallas Stars and NBA’s Dallas Mavericks. “So, when sidelined by an injury it is very difficult for them to know what to do each day and they feel somewhat ‘left-out’ from the rest of the team.”

To help with this, Collings explains that there is value in reminding them that they aren’t the only one with this type of issue. “I always try to let them know that there is at least one other player out there with the same type of injury with a similar recovery time,” she says adding that, “sometimes when they realize they aren’t alone, it makes it better.”

Set Realistic Expectations

“For the pro athlete, I want to set realistic expectations to their injury,” says Hirad Najaf Bagy, DC, team chiropractor for the Washington Redskins, Washington Nationals, and D.C. United pro soccer team. “I try to draw a picture for them what their injury is, what science tells us about their recovery, and what it means.”

In addition to setting realistic expectations, Bagy stresses that it’s also important to continually reevaluate. This helps the athlete “wrap their head around their injury,” he says, which can go a long way with keeping them motivated and positive, providing a better recovery as a result.

Communicate Clearly

“From the standpoint of a DC, and without the intervention of a Sports Psychologist, I believe that the most important way to keep the athlete mentally focused and motivated throughout the course of rehabilitation from an injury stems solely from clear and concise communication,” says Beau Daniels, DC, official chiropractor for the Los Angeles Rams.

“Making sure the athlete fully understands their injury, what to expect in the coming weeks, and what to expect regarding a return-to-play timeline is crucial to keep them focused on the growth they need to return to sport,” he says. “Athletes are very in tune with their bodies and unless you take the time to explain to them what they are feeling and how these feelings will change over time, you get a very confused and deflated athlete.”

Above All, Be Honest

“I think the best way that a sports chiropractor can help their athletic patients mentally is just being honest with them,” says Stuart E. Yoss, DC, CCSP, ART, team chiropractor for the Chicago Blackhawks, Bears, and Bulls. “The more you can tell the athlete what to expect also tends to allay any fears that they may have about being injured,” he adds.

Granted, this isn’t always an easy thing to do. “There are times that you will have to tell a patient their season is over or that they will have to miss the big game,” Yoss says. “Those are some of the worst times being a doctor. To see that look in their eyes is rough.”

DoCS is committed to raising the bar in chiropractic for athletes, so if you have any questions or article ideas, please feel free to contact us or share them in the comment section below. Reprints of this article permitted as long as it links back to the DoCS website: www.DoC-Sports.com.

Chiropractor Phoenix, AZ

Anyone who rides a bike regularly is probably well aware that accidents can happen, and may have even been involved in some close calls. Traveling on two wheels without a motor, means potentially putting yourself at risk of being struck by a car driver. If this were to happen, some bicyclists suffer from minor bruises and scrapes. But for others, the damage is much more severe. In many cases, an ambulance is required to rush the bicyclist to the nearest emergency room for immediate care. It is important to note that if the car driver was at-fault, the bicyclist may be entitled to compensation for his or her injuries, damages, and other losses.

In the aftermath of such an accident, a bicyclist may see their primary physician for an exam and treatment. Another great resource for those who were in a bike accident, is to seek care from a chiropractor. These medical professionals focus on injuries related to the musculoskeletal system, which is often seen in bicycle accident victims. Those interested in trying chiropractic care can consult with a doctor in his or her area for more information.

Statistics: How Often Bike Accidents Occur

It is estimated that more than half a million victims of bicycle-related accidents visit the emergency room each year in America. Common injuries include the neck, lower back, shoulders, muscle tears, broken bones, and head trauma. The bottom line is that riding a bicycle anywhere that shares lanes with vehicle drivers, is going to be risky. Bicyclists are vulnerable to serious injuries because they don’t have the same physical protection that car drivers have to deflect impacts. Bicyclists can help protect themselves by wearing safety gear, performing regular bike maintenance, and staying alert.

How Chiropractics Can Help Heal

Chiropractors can perform adjustments of the human body, particularly in areas where joints have become misaligned. For example, a person hit by a car is likely to suffer from spine and back-related pains due to the force pushing their body out of proper positioning. Once the spine and other joints are realigned, it can help reduce inflammation, decrease pain, increase mobility, and encourage the body to heal itself naturally. A chiropractor may recommend the bicycle accident victim receives massages too as a way to work through soreness, and practice stretching exercises at home to get back into riding sooner.

Areas Most Impacted by Bike Accidents

A bicyclist is likely to endure back, neck, spine, head, and extremity damage after being hit by a car driver. The victim may complain about tingling sensations, numbness, immense pain, stiffness, and other aches. A chiropractor Phoenix, AZchooses, like Dr. Monte Hessler, can perform a full-body examination, to determine the root cause before creating a comprehensive treatment plan. A bicyclist that experiences numbness in the hands or feet, may be suffering from compressed discs in the spine or from pressure on joints. A chiropractor can adjust these areas to aid in body healing. Neck and head injuries are frequently seen among bike accident victims, and can entail conditions like whiplash, concussion, trauma to cervical spine, and sprains.