Tuesday, April 28th20.1°C
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Back to Basics

Managing acute pain

Among the most common complaints that are treated in Chiropractic practice are acute low back and neck pain. These are often idiopathic (which means no specific cause) and in the short term can be disabling and painful.

When this pain hits it will greatly reduce mobility and make the simplest tasks such as shoulder checking or putting on socks incredibly difficult. The management of these acute episodes of pain has greatly changed over the last 10-15 years. Gone (hopefully) are the days of recommending bed rest, immobility and ice as the only interventions. It has been shown that this sort of advice will delay recovery and increase pain and dysfunction.

When suffering with acute pain there are several things that a person can do to help manage the pain in order to get through the day:

1.  Stay relatively active: This is particularly true with low back pain. The longer you lay around in bed or on couch, the longer the pain will typically persist. If there are no clinical contraindications, I advise my patients to stay active through walking or swimming etc. While this may be a little painful to start, generally as the body warms up, you will regain some mobility and associated pain relief.

2.  Avoid static positions: I’m talking to you salespeople and desk workers. Sitting down for a four hour drive or logging a full day in front of the computer is a recipe for disaster. I always recommend frequent micro-breaks in order to prevent long term immobility.

3.  Heat instead of Ice: Without any specific mechanism of injury such as a lifting, twisting movement or a whiplash situation there is no reason to ice. And even with those, most of the time people tend to do better by applying short bouts of a heat pack or hot shower to help maintain movement and control pain.

4.  Choice of anti-inflammatories: Many people are intolerant to products such as acetaminophen or ibuprofen due to abdominal or liver problems. There are alternatives that have been shown to very effective for pain control and act in an anti-inflammatory way. Tumeric and Bromelain (which are often combined) are very safe to take, affordable and in some studies rate more highly in effectiveness and patient satisfaction when compared to ibuprofen.

 

When to get checked

If the pain and disability has not substantially improved after 2-3 days it is a good idea to get checked by a qualified Chiropractor. Chiropractors are able to very accurately assess, diagnose and provide treatment options to patients which can safely and quickly relieve pain. Through a consultation, a Chiropractor will also be able to help you discover what sort of movements you should be doing more of and what ones are best to be avoided in the short term. Most importantly, with a thorough clinical exam, Chiropractors are able to identify red flags that reveal a complaint of pain if something more than strained muscles or a stuck joint.



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Selling fear

Communication is an often overlooked, but very important aspect of either doctor-patient or therapist-patient interaction. When patients refer friends and family to certain practitioners, it is because they obviously believe that practitioner is skilled in their field, but also they must have had some level of positive interaction as well. People don’t tend to refer their friends to jerks. Having a good rapport with patients is critical for doctors in order to establish trust so that patients are more likely to follow your recommendations. And as an obvious benefit for the doctor (especially one in private practice), those patients will return if and when future problems arise.

Over the last couple of weeks there have been a couple of very interesting blog posts written about the use of certain language used by doctors or therapists can that negatively influence patient perceptions and expectations (one of them written by a chiropractor is here). As an example I often review x-ray and CT scan reports with my patients in order to give a clear understanding of what they mean. Patients often are alarmed by the language contained in these reports because out of necessity in the radiology field, most reports contain wording that leads a patient to believe their ailment is more serious than it actually is. Phrases such as “degenerative changes” or “disk space narrowing” or “reversal of the cervical curve” give the impression to the patient that something is really wrong. And while this phrasing is technically appropriate and is required for clarity in report interpretation, how it is relayed to the patient is problematic. Patients hear these words and understandably get concerned. The problem is that most of the time these are changes that have been happening for years and are likely not related to the patient’s current complaints and are mostly normal for their age bracket. Most patients arrive in my office with acute musculoskeletal pain, which affects their function, yet doctors are quick to attribute their symptoms to structural changes (through imaging), which were present long before the new complaint.

In most instances (and especially with younger patients) imaging in the form of x-rays or a CT scan is not required and should NOT be used for dealing with musculoskeletal complaints. They should be used if Red Flags appear as part of the physical and orthopaedic exam that should be performed on a first visit. I have written previously on the use of both X-Rays and MRI in previous articles, which can be found here and here.

The job of both therapists and doctors in a clinical setting is to focus on enabling our patients; not to create fear and dependence. Patients have to be encouraged to move and to keep their levels of function and mobility high. I always try to encourage my patients to think about activities that they can be doing rather than what they shouldn’t. It is well know that regular activity is a much better treatment approach for aches and pains than rest and inactivity.

Sadly, some practitioners use x-rays to create that exact fear to set the stage for what is likely to be a long treatment regimen based on their ability to sell whatever treatment they use to “cure” what is likely not a major problem to begin with.



Ability to squat and lifespan

In my daily Chiropractic practice when helping patients with low back pain, one of the first movements I assess is the patient’s ability to squat properly. This may seem like a cruel thing to do to a person with back pain, but is actually clinically very revealing about why that patient may be in pain in the first place. Someone with poor squatting movement is much more likely to put undo stress on their lower back and more likely to re-injure themselves frequently throughout their lives.

In fact, a well known medical screening test known as the Sit to Stand test has shown that a person who has a poor ability to move from a sitting to standing position (essentially returning upright from a squatted position) has a 2 to 5 times higher mortality rate. The article regarding this test and the authors’ findings can be accessed here: Sit to Stand

The overhead squat is also one of the movements screens used in the popular assessment method known as Selective Functional Movement Assessment (SFMA). It assesses a person’s ability to squat fully to the floor with the heels down while holding a dowel overhead. It is actually a quite difficult task for a lot of people (myself included) and provides the therapist or doctor information about flexibility, mobility and trunk strength.

Being able to squat is an inherent human ability that we develop very young. Watch a 3-year-old squat and you are amazed by their ability to stay in that position, feet flat on the ground for long periods of time and be perfectly comfortable. As we get a little older and spend 12 years or much more behind a desk, we lose these inherent qualities such as ankle and hip mobility to be able to easily squat.

So now you can’t squat, but you still need to be able to complete low-level activities. So what do you do? You start bending at the waist, over and over again, throw in some rotation occasionally and in no time at all, you have a perfect recipe for low back pain. And by doing all that bending at the waist and avoiding squatting, you are further weakening your legs and glutes thereby impairing the likelihood that you will be able to achieve a squat or sit to stand movement in your later years.

What is the solution to this spiral? Squat and squat often. If you are unsure how to squat properly contact a knowledgeable health care provider who can teach you the proper technique. Learn how to squat properly and do it all your life. Chances are your life will be longer and you will have a significantly higher quality of life.



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Is the 'W' sit bad for kids?

You know when you were growing up and your mom or dad told you not to crack your knuckles because they would grow uncontrollably (not true) or not to stare into the sun because it would damage your eyes (likely true)? There are many things like eating your vegetables and taking your vitamins that we get told to do at an early age that has no discernable immediate impact but we are told to do it anyways. Fast forward 10 years and it seems like all the things we were told to do then are now terrible for us….hello low fat diets.

One of the items however that has actually been pretty consistent in growth and development is the 'W' sit for kids. This is of particular interest to me not only as a chiropractor but also as a father of one extremely flexible (and small) 4-year-old son whose favourite position is the 'W' sit. For those who don’t know what this is, sit on the ground in a kneeling position with your feet tucked under your bum. Then slide your feet out so that your bum can sink to the floor. Sounds awful right? And most adults can’t even come close to sitting like this because we simply do not have the muscle flexibility to do so.

I was first exposed to the idea that this was potentially harmful many years ago in pediatrics class in chiropractic school and then again several years later during a Dynamic Neuromuscular Stabilization course. Since that time, I have watched my son (who is made of rubber) naturally adopt this position and it has been a battle to undo.

Lots of young kids have the ability to do this and they love it because it allows them to sit up tall and be stable in the trunk while playing with toys. There are some problems with this position however and realistically it should be avoided.

The main long-term problem with this position from a structural view is that it causes tremendous internal rotation of the hip joint; which if allowed to continue can cause structural damage to the head of the femur and the acetabulum. Down the road, it can cause significant pain and be a culprit for an early hip replacement. It also can also contribute to tightness of the external hip and hip adductor muscle groups, since they are in a continuous shortened position with the 'W' sit. Lastly, because they are sitting in a relatively supported position, the kids do not have to actively use many of their “core” stabilizing and rotating muscles to accomplish their playing which can be detrimental to their overall motor development with tasks such as reaching across midline.

Teaching your kids to not rely on this position is easier said than done. For a lot of them (including my son), it is their default playing position and can be hard to correct. Kids who use this position love it and realistically it is probably the best position for them to do what they want; which is play. The alternatives such as criss-cross apple sauce, or sitting on your feet simply are not as comfortable for them and not as ideal for reaching for toys. This is a battle you as the know it all parent, however should be consistent with and encourage in a positive manner by showing alternatives instead of just saying “don’t sit like that”. My son still will often default to this position, however when reminded of it he will go through all the alternative postures for me. So it is not like he is unaware of the better strategies, he just doesn’t always listen to me. Apparently 4 year olds have an issue with that.



Read more Back to Basics articles

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About the Author

Dr. Nimchuk is one of a few full body certified Active Release Technique practitioners in the Okanagan Valley.  It has become known as the gold standard treatment for soft tissue injuries in athletics with almost every professional sports team in North America retaining the services of an ART certified Chiropractor.  Dr. Nimchuk has had the opportunity to work with many professional, Olympic and Ironman athletes.  ART is a patented, state of the art soft tissue system/movement based massage technique that treats problems with muscles, tendons, ligaments, fascia and nerves. Headaches, back pain, carpal tunnel syndrome, shin splints, shoulder pain, sciatica, plantar fasciitis, knee problems, and tennis elbow are just a few of the many conditions that can be resolved quickly and permanently with ART.  Dr. Nimchuk employs many different chiropractic techniques including manual and instrument adjusting along with ART.

In addition to private practice, Dr. Nimchuk is a frequent speaker and consultant to business organizations on topics such as ergonomics and workplace health.  Dr. Nimchuk is also registered as a Certified Exercise Physiologist with the Canadian Society of Exercise Physiology and has worked in many high performance and rehabilitation settings.

As part of his ongoing commitment to health and fitness, Dr. Nimchuk is a clinic instructor for marathon and 1/2 marathon clinics at the Kelowna Running Room and is also the Okanagan evaluator for the RCMP Physical Abilities Requirement Evaluation (PARE test).

To learn more about Dr. Nimchuk's treatments or to schedule a consultation, visit his website at chiropractorkelowna.ca or call 250-860-2212.




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The views expressed are strictly those of the author and not necessarily those of Castanet. Castanet presents its columns "as is" and does not warrant the contents.


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