Lumbar Spinal Stenosis

Older people commonly suffer from symptoms in their lower limbs due to a narrowing of the spinal canal.  This is called stenosis and the interesting thing is symptoms are NOT purely related to the physical narrowing of the bony canal.

As such many MRI reports indicate 'no evidence of bony canal stenosis' but does this automatically mean the person is not suffering from stenosis?  Well the answer is no and fortunately there is one sign (called a lumbar nerve root sedimentation sign) that is almost 100% indicative of stenosis.  It is thought to be partly due to the backing up of the blood supply of the spinal cord.

Like many conditions spinal stenosis can be identified early and treated effectively using conservative methods which are directed at restoring motion into these compromised areas.  More advanced cases may express weakness of the lower limbs and a loss of bowel and bladder function. These cases are appropriate surgical referrals. Research suggests however that when detected early management can effectively limit damage to the nerves and may slow or prevent deterioration.

Spinal manipulation and herniated discs

It's natural to question using spinal manipulation in the presence of a disc herniation.  After all discs only herniate when the outer fibrous rings (the annulus) are torn.  However if the disc is what is called 'contained' gentle manipulation can actually be very effective in controlling pain and restoring normal movement.

How?

One of the effects of spinal manipulation is a strong reflex analgesia, that is a potential pain blocking effect at the level of the damaged disc.  Another cause of disc mediated pain is swelling and a stasis or stagnation of the local blood supply (Bastons venous complex) to the sensitive linings which surround the spinal cord and part of the nerve root.

Many of these cases are unresponsive to steroid injection and other forms of analgesia and may often respond to manipulation.  Once the pain is under control the patient can undergo rehabilitation to prevent or reduce the risk of relapse.

Carpal Tunnel Syndrome - Axonopathy

CTS is being reclassified by some researchers as an axonopathy affecting the median nerve not simply compression of the median nerve as it passes through the carpal tunnel.

Again not all cases of CTS are the same.  This clinical ambiguity has led to controversial theories such as the 'double crush' theory which supposes that the median nerve may become irritated at multiple sites (neck and/or elbow and/or wrist) which can lead to a sensitisation of the nerve.

The nature of this neck or cervical involvement is still under debate, but most likely represents a central sensitisation of the pain pathways, rather than overt nerve compression.

For clinicians and patients widening the scope of attention to both proximal (close to the body) and distal sites can give us a number of interesting treatment strategies. These often include gentle spinal and carpal manipulation, as well as median nerve mobilisation and postural advice.


Douglas Scown

Posture - It hurts when I.....

References courtesy of CDI

References:
1. Bohns, V. K., & Wiltermuth, S. S. (2011). It hurts when I do this (or you do that): Posture and pain tolerance. Journal of Experimental Social Psychology.

2. Carney, D. R., Cuddy, A. J. C., & Yap, A. J. (2010). Power Posing: Brief Nonverbal Displays Affect Neuroendocrine Levels and Risk Tolerance. Psychological Science. 21(10), 1363–1368.

The people we see typically display crooked postures both when viewed from the back and side and it is common for these postures to change along with reported discomfort (ie people typically feel better the straighter they stand and the more freely they move).

What's going on?  There are two sides to the issue.  The force of gravity on poorly aligned and controlled structures (posture is dynamic and constantly changing) makes them fail and hurt but posture also influences both our state of mind and our ability to feel pain.

In short improving ones posture and movement can increase our tolerance to pain and our feelings of control over pain.

Migraine - A brain disorder

Our view of migraine needs to change.  It's now established that it is a condition whereby the brain can't easily control (INHIBIT) the many sensations which constantly flood into it from all areas of the body.

Headache is only ONE symptom of migraine and often it is not even the most bothersome.  Fatigue, cognitive problems and other body sensitivities commonly overshadow any head pain.  The headache itself can change over time leading people to believe that they grew out of migraine.  They will remark "I don't get migraines any more, just tension headaches (which may become chronic).  Tension 'Type' Headache is even seen by some researchers as being a form of chronic migraine type headache (there has never been any scientific evidence of muscle 'tension' in the scalp)

Head pain can actually be a major distraction because if the actual problem (a brain regulation issue) is not addressed the disorder will be poorly managed.  Many migraineur's go through life thinking they are just unlucky because there appear to be so many different things wrong with them when in fact they are all symptoms of the one condition.

So these days Migraine = headache is like saying Earth = Flat.  It certainly appears that way but the reality is entirely different.

Migraine - It's an elephant

Migraine affects 10% of the population and it's believed about 20-30% of the individuals who consult chiropractors. 

This is an old Hindu/Buddhist story.  5 blind men examine the same elephant.  When asked what is it they give very different answers.  What's more their answers confuse the other 4 men.  Eventually they take off their blindfolds and realise they had different ends of the same beast not different things in themselves.

Migraine is like the elephant.  Headache is the trunk, IBS the tail, restless legs the foot, fatigue, 'stress' and again the symptoms can be diverse and APPEAR unrelated.

Research now reveals that migraine is a brain problem.  More specifically the brain has trouble controlling sensations.

There is so much information about migraine these days that it's awfully confusing.  Essentially the migraineurs brain is low in serotonin (which has multiple duties - pain and mood control) and other materials ('substrates') such as Vit D and magnesium which nerves use to function.

Because the brain cells can't 'run' themselves properly they can miss fire - the result is disordered brain activity in particular parts of the brain.

So one approach is to provide the brain with these materials.  One material that has been researched well is Co enzyme Q10.  Another is Vit D although it's a specific type of D and a blood test is required to check it's level.  There are also other genetic tests.

The goal here is to make the brain cells more robust and efficient; stronger if you will.

The other side is to identify and reduce triggers or irritants.  Some triggers are foods or bright light.  Many triggers don't 'work' all the time.  It depends on the individuals general neurological robustness.  For example you might 'get away' with a red wine today but add some fatigue, lack of sleep (a well known progenitor of migraine) and hey presto - symptoms.

Spinal 'derrangement' adds another 'somatic' component in some individuals.  In normal situations a 'stiff' neck might result in nothing more than local discomfort.  In a migraineur it can trigger a host of symptoms and effectively end a persons day.  Furthermore migraineurs display more scoliosis and postural issues than the norm and we know now that these things are largely brain issues as well.

 

The glass here represents the brain.  The water is the constant but variable inflow of sensations from the body.  We can identify and control potentially noxious or overloading input and we can supplement the brains mineral and chemical substrates.

Migraine - When normal sensations become gate crashers!

gate·crash·er (gtkrshr) n. Slang One who gains admittance, as to a party or concert, without being invited or without paying. gatecrash v.

Underastanding migraine first requires a change of perspective because it's still seen as being 1. A headache and 2. Episodic (ie it comes and goes).

Well migraine is not a headache and because it's genetically linked it never 'goes away'.  What's more over time the symptom of headache can become secondary to the other more diffuse and challenging aspects of migraine itself.

One big function of the brain is to STOP feelings or sensations.  It's called INHIBITION.  But the disorder of migraine results in a brain which has trouble stopping normal sensations (from the head or guts or anywhere else) getting through.

As a result a migraine sufferer typically gets head, gut, leg, body discomfort/sensitivity and is prone to extreme fatigue, anxiety/depression and is more likely to suffer from a whole host of so called co-morbid conditions many of which are likely manifestations of the disease itself.