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Spine Surgery

Getting a Safe Correction after Spine Surgery

Spine Surgery

Read Time: [3 minutes]

Over the past few weeks, I’ve been seeing a lot of posts about this article filling up my Facebook newsfeed. The article talks about how a specific type of spine surgery called spinal fusion has been found to be mostly ineffective. The author goes so far to say that the surgery should be put to rest.

rip-fusion

Article by Dr. Chris Centeno http://www.regenexx.com/nejm-back-neck-fusion-surgeries-not-needed/

I’ve seen a lot of patients with a previous history of spinal fusion. Some people feel like their life was made dramatically better by spine surgery, others feel like it didn’t have any effect at all, and some people will actually feel a lot worse. Overall, the verdict on fusion surgery seems to be pretty dim.

People Don’t Volunteer for Spine Surgery. It’s a choice made out of desperation

Here’s the thing. I don’t blame people who choose to elect spinal fusion even in the face of the world’s best evidence. Why?

I’ve never experienced the level of pain that makes someone consider spine surgery an option.

It’s the easiest thing in the world to be a chiropractor, physical therapist, or pain management doctor to tell someone that they don’t need spine surgery. Our professions are invested in the idea that you should choose us over surgery because you should exhaust your conservative options before being cut open.

However, someone who is choosing spine surgery is often someone who is desperate. Their pain is debilitating and costing them the ability to work and move like a normal human being. Many patients have tried numerous conservative options and feel like they have spent years feeling debilitated. They are tired, frustrated, and just want something, anything to make their pain go away.

I hear it in my office all the time. “Doc, can you just cut this thing out of me?”

Sure it’s said in jest, but it opens a window to what someone’s last option looks like. Just cut me open, and take whatever is causing this pain, and remove it.

You’ve had surgery, now what?

People that choose surgery often feel like they’ve exhausted all possible treatment options.

If your pain didn’t improve or if you develop or new and worse pain after surgery, it can be devastating to the psyche. You tried everything and it still didn’t work. Will you have to suffer like this for the rest of your life? Do I just have to rely on pain management and more surgery?

From time to time, I’ll meet people who tell me about how bad their back or neck problems are, but they’ll usually say something like:

But I’ve already had surgery, and my doctor says I shouldn’t have my back cracked.

I understand this fear. If I had hardware in my spine, the last thing I would want is someone just jerking my back or neck around and possibly hitting one of those fused parts.

Here’s the thing though. Not all chiropractic techniques require heavy force.

There are a lot of chiropractors trained to be extremely precise with their adjustments. With a high level of precision, you can avoid doing anything to the spine that may jar or disturb these fused vertebrae.

This is important to remember because precise Structural Correction of the spine is something that can really help these patients! It’s one of the reasons that there are doctors in Palm Beach County that refer cases to our office when patients still have pain after surgery.

The Problem Isn’t Just the Spine, it Might Be in the Brain

Pain is a complex physiological phenomenon. As doctors, we can sometimes oversimplify back and neck pain as a bad bone or a bad disc. The fact that people don’t get better after surgery isn’t the fault of the surgeon. The problem is that the bones and discs in the back may not have been the actual cause of the pain to begin with.

Pain can exist in the absence of physical tissue damage as is often seen in things like fibromyalgia or complex regional pain syndrome. In these cases, there is a problem with the way the brain perceives the environment. It is overreacting to normal stimuli.

When people have successful cases with surgery, then we can probably assume that a bad disc or some bad vertebrae were big contributors to the patient’s pain process. However, if we are operating on patients whose symptoms are coming from a brain that is overly sensitive to pain, we are giving that sensitive brain more ammunition to be in pain because of the surgery itself.

Sometimes the answer is not simply to change the bones, but we have to desensitize the brain to normal living.

That’s one of the biggest unknown benefits to Structural Correction with the NUCCA procedure. Normal Structure plays a vital role in normal input into the brain. Our gentle approach to correcting the spine is capable of changing the signals the brain should be focusing on and reducing some of the chronic inflammation impacting your sensitive brain tissues.

Changing the Conversation

Millions of people every year are going to have spine surgery. It’s up to the doctors and surgeons to decide if surgery is appropriate for a patient’s situation. There’s no use in beating a patient up for making a decision that they think is going to help them live a better life.

It’s our job to let people know that whether you had surgery or not, there are still options available to help people live a normal life without feeling debilitated.

Ask Dr. Chung a Question

Pinched Nerve

Anatomy of a Pinched Nerve

Pinched Nerve

Read Time: [6-7 minutes]

After the wide success of my article Anatomy of a Headache I decided to tackle another common problem we see every single day in the office.

Pinched Nerves

When someone gets an acute pinched nerve, it can be amongst the most painful problems that afflict human beings. Pinched nerves can leave people in lying in bed with an inability to work, exercise, sleep or play. When it happens people take on really strange and awkward postures to try to avoid the pain.

If you are like Mr. Stock Image here where you lean away to one side and lift your arm, you might have a pinched nerve in your neck. Image Credit: Can Stock Photos

If you are like Mr. Stock Image here where you lean away to one side and lift your arm, you might have a pinched nerve in your neck.
Image Credit: Can Stock Photos

 

But there’s a lot of misconceptions about what a pinched nerve actually is. A lot of people feel like if their neck or back has a pinching or stabbing type pain, then it’s likely a pinched nerve. However, multiple types of neck pain can lead to a pinching type of pain.  A true pinched nerve involves multiple factors.

1. A Tissue Offender

There are several different types of tissues that can pinch a nerve. Bone, muscle, tendons, and calcified ligaments are all compress nerve tissue throughout the body. Even tumors can cause pinched nerves, but those are in much more rare circumstances.

The overwhelming majority of pinched nerve pain stems from a problem you’re probably familiar with. The slipped/herniated disc. Tearing of the outer part of the disc allows for a gel like material to spew out into a small space where a nerve travels.

Most herniated discs don’t cause problems. I can take an MRI of 100 random people with no pain and chances are high that many of them will have a disc herniation.

The herniation only becomes problematic when it is large enough, or you move in a way to force this gel into the nerve against some of the other hard structure in the spine.

When a disc breaks down and leaks a hard fluid on top of the nerve, the nerve can become pinched between a rock (bone) and a hard place (disc) Image Credit: Can Stock Photos

When a disc breaks down and leaks a hard fluid on top of the nerve, the nerve can become pinched between a rock (bone) and a hard place (disc)
Image Credit: Can Stock Photos

2. Soft and Sensitive Nerves

Nerve tissue is soft and sensitive. Even small amounts of pressure against a nerve can make it go haywire. They are like the iPhone charging cables of the tissue world. Just a little bit of stress and the whole thing comes unraveled.

That’s why your body protects the most sensitive nerve tissue (brain, spinal cord, spinal nerves) in a case of bone called your skull and your spine.

But it’s not just sensitive to pressure. It’s also sensitive to chemical signals like inflammation. Which brings us to the third important piece of anatomy.

3. Inflammatory Chemicals

Inflammation from a torn or damaged disc can build up around the nerve and stimulate the nerve to create a pain response. This is especially true when you injure a disc very suddenly….like in a car accident or picking up a heavy box. Cells from your immune system rush to the site of damage and try to clean up the mess. The result is a large number of inflammatory molecules called cytokines and substance P fills that area and can trigger a pain response from the nearby nerve.

I always compare the body’s use of inflammation to a fire/burning process. When your body uses inflammation it is like using a fire to burn away germs or damaged tissue in the body. The main problem with fire is that it can sometimes cause damage your own body too. This is especially problematic when inflammation affects a nerve.

Image from published article: Inflammation ain intervertebral disc degeneration and regeneration. Journal of the Royal Society Interface. 2015. http://rsif.royalsocietypublishing.org/content/12/104/20141191

Image from published article:
Inflammation ain intervertebral disc degeneration and regeneration. Journal of the Royal Society Interface. 2015.
http://rsif.royalsocietypublishing.org/content/12/104/20141191

 

When a Pinched Nerve is a Serious Problem

The pain from a pinched nerve can be excruciating. It’s not uncommon for someone with pain from a fresh pinched nerve to go to a hospital to get checked for something serious.

With that said, the pain from a pinched nerve is not the worst thing that can happen. The worst case scenario for pinched nerves are a loss of function.

If you have a pinched nerve and you start to have things like weakness and complete loss of feeling in your arm, legs, or hands, then it can be a serious issue that needs to be addressed by a surgeon. In cases of pinched nerves in the lower back, sometimes the nerves can affect bowel and bladder function leading to a condition called Cauda Equina syndrome which is a medical emergency.

If left for too long, your muscles can begin to atrophy and you may never get full function back. These are scenarios that shouldn’t be trifled with.

90% of Pinched Nerves Can Be Addressed Conservatively

That previous section wasn’t meant to scare you, but it’s a reality that we sometimes we have to face. The good news is that the vast majority of pinched nerves respond great to conservative care. That means things like physical therapy, anti-inflammatories, and decompression can all be helpful modalities in dealing with pinched nerves.

All of the above therapies can provide some relief from the pain of a pinched nerve, but one thing that is important is addressing some of the biomechanical issues that lead to a herniated disc becoming a pinched nerve.

 A Delicate Balancing Act

The spine has many functions. It protects the delicate spinal nerves, it’s the central attachment point for numerous muscles, and allows for a wide range of movement. Another key function is the way that it distributes force throughout the body.

One of the key facets of Normal Structure is that it provides an ideal way for the human frame to distribute force evenly through the body’s muscles and joints. When we lose normal structure, we start to put more stress on some parts of the body over others leading to increased joint stresses in select areas.

body imbalance

Loss of Normal Structure leads to abnormal joint stresses

Want proof that your structure exacerbates pain from a herniated disc. Look at the way that people hold their posture. People with pinched nerves usually can’t stand bending their neck or back in a specific direction, so they lean towards one side over the other. You’ll also see that they avoid forward bending too.

But why? Because bending forward and into the side of the pinched nerve will increase force into the disc and force it further into the nerve.

When your spine bends forward and to the right, it's going to push that purple-ish goo further into the nerve

When your spine bends forward and to the right, it’s going to push that purple-ish goo further into the nerve

That’s why correcting the underlying foundation of the spine helps with pinched nerves because we can help the body naturally equalize the forces going into your discs. Sometimes the body will actually find a way to make the herniated disc go away! Although it’s not expected, the body is always going to move in a direction of healing itself, and sometimes that means getting rid of an offending disc problem.

Ask Dr. Chung a Question

#1 Lifting Error

The #1 Lifting Error Seen in Every Crossfit/Lifting Gym

#1 Lifting Error

Reading time:  [10-12 minutes]

Outline:

  • The counter intuitive movement that is causing most back injuries
  • Set up and clean up are where the most glaring lifting faults happen
  • Can light weight with broken form cause injury?
  • How we lift heavy things is how we should lift everything

Despite my general dislike for the lift in the title graphic, this post isn’t going to attack the sumo deadlift high pull. In fact, it’s not going to address the deadlift, snatch, clean, squat, or any of primary movements in Crossfit.

I am a firm believer that almost every exercise has an appropriate time and place when it is performed well and programmed appropriately. Despite the bad rap that Crossfit has gotten for poor instruction, most Crossfit coaches and long time Crossfit enthusiasts actually understand the general mechanics and teaching of the primary movements.

My beef in this post has to do with what happens BEFORE and AFTER workouts.

Set-Up and Clean-Up: Where Good Form Becomes Trash

So let’s talk about what happens for the average Crossfitter when they’re about to perform a heavy lift off the ground. Imagine the times in your life where you are lifting something for 90%+ of your 1-rep max:

  • You approach the weight straight-on to optimize the direction of force.
  • You hinge from the hips to grab the weight.
  • You create a straight lumbar and thoracic spine making sure you reduce your back curvatures as much as possible.
  • You breathe in and brace your abdominals.
  • You lift and generate a powerful upward force through your hips

Whether you nailed the lift or missed it, you complete the attempt satisfied that you at least had decent form and that you’ll be back to lift another day.

Time for clean-up:

  • You reach down to the bar lumbar and thoracic spine fully curved
  • You pick up the bar slightly with at an odd angle with no abdominal brace whatsoever
  • You pull the 45 lb plate off the bar with a relaxed hunch back and load all of the lumbar soft tissue
  • You reach down and grab the 45 lb plate flat off the ground again with a curved back, lifting almost entirely from the lumbar spine.
  • Repeat until all of your weight is gone

“Dr. Chung, those weights are light. They can’t hurt me.”

For the coaches and experienced lifters who are reading this: you know you would never let someone get away with a slouched posture when you are teaching them to deadlift. It doesn’t matter what fitness level that person is in, you know that lifting with a rounded spine is mechanically flawed, so you will always give them cues to change their pattern, even if it was an unloaded barbell.

 

Thanks to Coach Rachel Locker from Crossfit Liger for the demo

Thanks to Coach Rachel Locker from Crossfit Liger for the demo

 

There’s an interesting thing that happens to a trained lifter as you add more weight to a barbell. Instinctively, you know that if you don’t brace your abdomen and bring your spine close to neutral, you will be unable to get the weight off the ground. Plus, you know your back will become more exposed to danger.

There are couple of things that happen when you lift with an unbraced spine:

1. You exponentially increase the amount of shear force going into the lumbar spine.

Shear is when you have part of your back moving one way, and another part moving in the opposite direction. In of itself it’s not bad, but when you add compression by picking up a weight or applying load, it’s like rubbing sand paper against each other….except the sand paper will be your discs and ligaments.

Just as an example, the deadlift on the image on the above left may place about 2000 N of shear force into the lifter’s back, while a braced spine can reduce that force down to 200 N. When you keep your back close to neutral, you activate your extensor muscles which help to reduce that shearing force to the disc and ligaments. Rule of thumb: muscles like to be loaded, but ligaments and discs are sort of like a “break in case of emergency” system, you want to load them lightly, and not terribly often.

2. Repeated rounding of the back (flexion) peels away layers of your spinal discs.

This is why sit ups are generally an exercise that is associated with back pain because the repeated flexion has the ability to peel away layers from the discs like an onion. This creates a weakening of the disc tissue which can increase the liklihood of herniation.

The muscles of your trunk are designed to prevent the veretebrae from moving too much. The muscles of the trunk are best utilized to create stiffness and to resist bending under load. Approaching weights with a braced, neutral spine is the body’s defense to load. Doing static trunk holds like a plank instead of repeated bending motions (sit ups, toes to bar) can save these layers in your discs.

When you are lifting heavy objects, you are doing it for less repetitions, and your’e also more likely to lift with a braced spine. When are lifting light objects, or just going through the motions of clean up, you are lifting for a higher number of reps with a spine that’s less likely to be protected.

In a way, you may be placing MORE shear forces into your spine lifting a 45 lb plate off the ground unprotected, than lifting a 135 lb bar off the ground with a braced spine. You’re also picking up that 45 lb plate off the ground with broken mechanics day after day.

Biomechanically picking up the plate off the ground like this is similar to picking up the barbell with a flexed spine.

Biomechanically picking up the plate off the ground like this is similar to picking up the barbell with a flexed spine.

Remember that it’s USUALLY the slow and gradual wear and tear that ends up hurting people. You may not hurt yourself while cleaning up equipment, but you are creating an environment that can make a back injury increasingly likely.

I have patients that tell me all the time:

“I went down to pick up a pillow, and then my back just seized on me”

It’s really unlikely that the pillow itself caused the back to go out. The truth is that the discs and tissues of the back were degenerating for a long time before that incident.

How you lift anything is how you lift everything

Whether you have a current episode of back pain, never had pain before, have a history of pain, lifting something light, or lifting something heavy, the process of picking something off the ground should be the same.

After working with thousands of patients and numerous organizations, I’ve seen that you can dramatically improve the life of a patient with back pain by simply teaching them how to move differently.

One of the concepts that I teach is to approach ANY type of lifting with that of a weight lifter. Why like a weight lifter? Because they are literally capable of moving weight far beyond the average human without becoming a victim of catastrophic injury. They are also lifting heavy loads daily without aggressive deterioration like we would normally see in occupational lifting.  In other words, they have a great model to follow.

If you’ve read this far and are still interested, that means you have to be a Crossfitter, so let’s compare and contrast where these common movement faults happen during clean up.

Stripping the Bar

Lumbar flexion occurs commonly when stripping the bar. The bending plus the lifting of the bar to strip the weight can be awkward on the lower spine.  Some can straighten the back and pull off the weight like the picture above. Alternatively, a straight leg hip hinge can be used without lumbar bending.

Lumbar flexion occurs commonly when stripping the bar. The bending plus the lifting of the bar to strip the weight can be awkward on the lower spine.
Some can straighten the back and pull off the weight like the picture above. Alternatively, a straight leg hip hinge can be used without lumbar bending.

Lifting Weight off the Ground

People often bend down from their knees and their back to pick up weights from the ground. With these weights, the bending isn't as much of the problem as the lack of abdominal and lat bracing. Bringing a flat back can cue bracing strategies easier and treat the lift as a deadlift instead of a sloppy forward bend.

People often bend down from their knees and their back to pick up weights from the ground. With these weights, the bending isn’t as much of the problem as the lack of abdominal and lat bracing.
Bringing a flat back can cue bracing strategies easier and treat the lift as a deadlift instead of a sloppy forward bend. ***The same strategy applies to lifting an unweighted bar off the ground***

Take a look around the gym next time and observe how people set up and clean up their weights. Does the image on the left look pretty familiar? Compare and contrast to how the image looks on the right. No matter what the load is, you can apply weight lifting principles to execute the task at hand.

My Own Personal Experience

When I was getting ready to open my practice in Wellington, I spent an entire week painting baseboards in a broken and slouched position. It was the first time in my life that I ever had back pain. Not from 10+ years of weight lifting and 3+ years of taking care of patients. Nope, just 1 week of painting baseboards.

It blew my mind that people can do this every day of their lives.

Of course I didn’t want to stop training, and I couldn’t stop working to get the office ready for our grand opening. I had to figure out how to move without worsening the mechanical stresses on my spine.

On top of getting my spine corrected by my chiropractor, I applied the same principles in today’s post to doing all of my tasks. I was hip hinging to pick up every object, whether it was a paint brush or a heavy desk. I braced my trunk while painting to limit any further shear. I was also paying way more attention to how I set up and cleaned my weights.

Sure enough, I didn’t have any back pain when I started implementing these strategies.

While these steps are useful for people who don’t want to have their backs wear out as a preventative measure, they are critical for the patient with back pain to preserve their spine and still maintain the ability to work and play.

Start playing around with this the next time you’re at the gym or at work and see how it feels. If you want a more comprehensive assessment of your movement and your structure, then feel free to comment or message me below.

 

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2 + 6 = ?

 

Why Does My Back Hurt When I breathe

Why Does My Back Hurt When I Breathe? What is it and how to fix it?

Why Does My Back Hurt When I breathe

Outline

  • Pain from the ribs. How’d it happen?
  • Why does it hurt so bad?
  • Painful but fixable

 

“It hurts right here (points to middle of back), especially when I take a deep breath in.”

“It’s like someone is poking a knife in the middle of my back”

“Every time I try to stand up all the way, my back spasms.”

“I just want to crack this pinch in my back.”

 

There are times when pain can literally take your breath away.  I know this feeling well because it’s one of the main things that brought me to the chiropractor’s office for the first time. That sharp, stabbing pain coming from a very pinpoint spot in the middle of your back.  Sometimes it’s just a really annoying feeling that won’t go away, but other times it can make you feel crippled by back spasms.

In many cases, this pain comes from the joint where your ribs connect to your spine. Sometimes people will say that you have a rib head that’s “out of place”, misaligned, or sprained. For the sake of today’s article, we’ll just call it rib pain.

It’s a frustrating problem because it can happen out of no where. Sometimes you just wake up with the pain, other times it’s from twisting or turning too quickly, and in my case, it was from lifting too much weight overhead. Fortunately, even though we don’t know much about the pain, we do have effective strategies to help manage it when you feel it.

Why Does It Hurt So Bad?

The interesting thing about pain from a rib head is that the intensity and level of annoyance is really high for a problem that is pretty harmless. It’s not like a herniated disc where you may have other serious complications that arise, but the pain can sometimes be as debilitating.

Although this joint won’t result in pinched nerves that can cause muscle weakness or loss of feeling, it is extremely dense in pain generating tissue.

Rib Anatomy

The ligaments shown on the image above, as well as the direct connection of the rib to the vertebra can be full of pain fibers called nociceptors. This joint is not supposed to have very much movement. If the joint gets overloaded and sprains the ligament, or if there is too much friction between the joint surfaces, then it stimulates an aggressive pain response in the brain.

 

Rib Muscles

When the pain response is initiated, the nervous system often looks to brace an area of injury, this typically comes in the form of muscle tightness and spasticity. As the muscles tighten around your ribs, it limits your ability to breathe in deeply. The muscle spasticity may also compress the nerves, arteries, and veins passing around the curvature of the ribs causing additional sources of pain and discomfort.

Unlike other parts of the body like the hand, shoulder, and low back, you don’t have a choice in moving your ribs. Your ribs move whenever you take a breath, and breathing is a little bit important to the maintenance of life. The more it moves, the more it can agitate the painful joint even if there’s minimal tissue damage.

How to fix it?

For most people, this pain will go away within a week without any treatment. However, if you have the pain for longer, you may need a little bit of outside help to correct the problem.

Most chiropractors can address the pain with a spinal adjustment to the thoracic spine or rib head. Typically patients will feel a substantial amount of relief within a few visits. When combined with some corrective exercise, you probably won’t have any further issues unless you reinjure the joint.

After my weightlifting injury I found myself having rib pain repeatedly even though I was getting regular adjustments to my back. You can say that I had chronic rib problems because I struggled to get long term relief.

I didn’t get long term relief until I got my upper neck corrected which finally seemed to make my spine maintain itself for months instead of a few days at a time. The way the neck influences the structure of the spine led to persistent muscle imbalance in my thoracic spine. Just like the image below, when the hips and shoulders rotate inappropriately, the rib cage can become a problem area.

Upper Cervical Distortion

 

Whether your problem is brand new or chronic, a Structural Corrective approach to the spine can lead to substantial relief.

Did you like this article? Feel free to share it with the people you care about and see if a Complimentary Consultation is the next step to regain their health. Dr. Chung is a practicing Structural Chiropractor in the West Palm Beach area. He has been published in peer reviewed scientific journals.