Do you feel that behind your thigh or in your calf?

You think you are stretching your hamstrings? Well, you’re not. At least not likely. Why is it necessary to even discuss stretching?

Why Flexiblity is Important

The ability to move in a full range of motion is important because we use our bodies the way we were meant to move. We use ALL of a muscle instead of only a part. We use ALL of our muscles instead of a specific few. This is healthy, balanced movement.

Once we start losing flexibility, our tightness snowballs. My grandmother would ask me at least once a day to get something out of the cabinet for her that was right above her head. My grandfather didn’t have the flexibility or strength to perform a squat; he died as he fell going to the bathroom, hitting his head on the sink on the way down.

Flexibility allows movement. Movement allows the body to function. You (and your grand-kids) can be happy because you are able to do everything you want and need to do in life.

How to Make a Human Cell Out of an Apple

Flexible people made themselves flexible. Inflexible people made themselves inflexible. Everything we do has a cause and an effect.

It is easy for us to forget sometimes just how amazing the human body is. We start life as a single cell. We can put all of the most brilliant minds with all of the money and technology in the world and they still wouldn’t be able to turn an apple into a human cell like the human body can. We can observe the world, and adapt to it. We can treat our bodies like garbage, disrespecting it with poison in the form of processed foods, alcohol, and chronic sitting, and still live a mid-range life into our 60’s.

Being as amazing as it is, everything that our body does is an adaptation to the environment we put it in. Every disease or condition is a SMART response from our body.

Arterial plaquing is a condition characterized by the accumulation of fatty plaques and inflammation in our blood vessels. Too much sugar damages our whole body, including the blood vessels. Plaquing is the body’s attempt to patch the holes caused by the presence of too much sugar. Everything has a cause!

Conventional Wisdom – To Stretch or Not to Stretch?

Fitness enthusiasts and healthcare practitioners alike say “if a muscle is tight, stretch it.” This is a very general level of detail. In order to get to the bottom of “tightness,” we need to delve a bit deeper into specificity.

If everything our body does is smart, why is your hamstring “tight?” A muscle can be “tight” for 3 reasons:

1. Actual mechanical stiffness

According to the “use it or lose it principle,” our body will use energy for necessary body processes because we evolved with a limited food supply (unlike American culture today). Using our muscles in large ranges requires energy. Being efficient, if we don’t use our muscles, our body makes our active muscles passive so that they don’t require energy, thus conserving it for other processes. This is the stiffness that occurs.

This mechanical stiffness is the only reason you would want to stretch a “tight” muscle. A “normal” stretch should be experienced in the whole muscle, not a small part of it. So if you are stretching your hamstrings, you should feel the same intensity stretch from your butt to your knee.

2. Adhesion

Muscles, ligaments, tendons, and nerves develop adhesion (a form of scar tissue, that by definition, formed without trauma). Adhesion is like taking a piece of gum and putting it between muscles, ligaments, tendons, or nerves so that it becomes difficult for them to slide past one another when moving. It is another way to make muscles stiffer as to conserve energy. But it also is a result of tissue overload and injury.

Overloaded muscles without the proper healing environment will heal with adhesion because the damage done cannot be optimally repaired. Overload can occur from:

• doing the same exercises day after day (too much bench press)
• holding the same postures such as sitting or typing or playing an instrument
• stretching or shortening a tissue for too long

3. It’s protecting something.

Yes, your hamstring contracts to protect you. Certain tissues of the body are more sensitive than others, especially when already irritated or overloaded. Nerves are particularly sensitive because once damaged, they have limited healing ability.

The sciatic nerve is a nerve the size of your index finger running down from your butt to behind your knee where it splits. Because of our sedentary lifestyle, this nerve is apt to developing adhesion between it and the muscles it runs near due to the pressure (sitting on our butt) and stretch (sitting puts tension on the sciatic nerve). Again, imagine multiple wads of gum stuck between this nerve and the muscles. As you bend forward at the back and hips, you put tension on the sciatic nerve (will often be felt in the calf!). If it is adhered and stuck, it won’t like being pulled. Hence, your body contracts your hamstring so that you don’t put any more tension on the nerve.

The 2nd and 3rd conditions are more common than the 1st. This is evidenced by the number of people who stretch without effect, not becoming any more flexible and staying in pain.

What To Do

1. Prevention is the first step: Move often. Don’t do any activity (ie. sitting) for longer than 30 minutes without stretching and moving that muscle in its full range of motion for a couple of minutes. So do a 2 minute lap to get a drink of water every 30 minutes at your desk job. Move your wrist as far as it will go back and forth for 10 repetitions when taking a break from playing an instrument or typing.

2. Perform exercises in a full range of motion with good form. This tells our body that we need to use the full range of our muscles and maintains our flexibility.

3. If tight, perform dynamic stretching. This is stretching into a lengthened position, holding for 2 seconds, then coming out of the stretch. Perform repetitions of 10 before and after workouts. Also, doing this throughout the day is not a bad idea.

If daily stretching does not get you increased flexibility after a couple of weeks, chances are that you have significant adhesion in that area of your body. Continued stretching of adhered muscles or “protective contractions” may make it feel better temporarily. But stretching nerves for long periods of time is not healthy and can contribute towards significant damage. If chronic pain goes along with that inflexibility, an Active Release Technique (ART) provider can help you with this specific problem.  Active Release Technique is quickly becoming the gold standard in soft tissue treatment.

Stretching and flexibility is an area of fitness and health that is overlooked. While stretching does have a place, it is not the be all-end all to the “tightness” you experience. If it doesn’t help, you weren’t born tight.  Just don’t let your inflexibility progress until you can no longer do the things you love in your life.

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ACA

Choosing a chiropractic college is an important decision that many students fail to recognize. Of the schools, some have radically divergent theories, philosophies, and treatment methods. To many students choose on the basis of proximity and their own chiropractors recommendation, which can land them in the wrong institution.

You may view student ratings of some of the chiropractic colleges, but at this time only a few colleges are rated.

The following article addresses the key considerations when choosing your chiropractic institution.

Key Tenets

Philosophy

Probably the biggest defining factor between most of the schools.  Some schools focus heavily, or even exclusively on the philosophy. So what do I mean by philosophy? Philosophy is the theory as to why chiropractic works and thus how to treat your patients. At times it can almost become dogmatic in its approach.

The type of philosophy can vary dramatically too. Some schools are known as ‘mixer’ colleges. At these institutions chiropractic is seen as on of the many tools a chiropractor can provide to heal their patients, along with nutrition, modalities (Electrical stimulation, ultrasound, cold laser, etc.), soft tissue and muscle work, and exercises. Other schools that are more ‘traditional’, primarily focus on the manipulation of spine.

Schools that focus highly on philosophy include… Life College and Sherman College.

Science

To diagnose properly, and recognize diseases outside of a Chiropractor’s realm, one needs extensive teaching in science. This includes anatomy, physiology, physics, pathophysiology, kinesiology, chemisty, and so forth. Some chiropractic schools excel in this department, competing with medical colleges in the content taught. Others offer a more basic science education, often associated with their greater emphasis on the philosophy.

Schools that focus highly on science include… National University of Health Sciences, New York Chiropractic College, and Western States.

Art

Adjusting techniques and patient interactions. This is really the bread and butter of a chiropractor, and of course every school is going to tell you their technique program is the best. In all reality, pretty much all the schools provide a roughly equal education, and its really up to the student to take it as far as possible.

The schools however do teach different techniques, so for example if your doctor uses Toggle on you, and you love it, a school like NYCC which doesn’t teach it in its core curriculum may be a poor choice. Make sure when talking with school representatives to find out what techniques they include in their core teachings.

Business

The unfortunate reality is that chiropractic is ultimately a business, and unless you’re a trust fund baby, if you want to eat you better learn how to run and advertise an office. The importance of a good business education is really dependent on your plans post chiropractic school. If you plan on going solo, you need all the education you can get or your odds of failure go up tremendously. If you plan on being an associate, most likely you’ll get plenty of training in that department.

A key item to ask the college representative is how you obtain patients when you enter your clinical trials. Some colleges will provide the patients, others make it your responsibility.

Schools that focus highly on business include… Parker College.

Location

Ok, ok, I know I played down this factor, but it is important. If its located somewhere that really isn’t you, you’ll be miserable and education will suffer because of it. For the county bumpkin:  New York Chiropractic College and Palmer College. For the city slicker… National University of Health Sciences and Life University. For the beach bum…  Palmer College Florida for example.

In Summary

At the end of the day, all of the colleges only have so many hours to afford in any type of class, and thus ‘best’ college really depends on what you are looking for. But don’t leave it all to location.

Proper Lifting Techniques

You have heard it before. “Bend your knees when you pick that up or you’ll hurt your back.” Well, that’s true, to a degree. The fact is though, simply bending your knees is not enough to prevent low back injury.

The reason chiropractors, physical therapists, and personal trainers alike advise bending your knees is because they do not want you to put stress on your low back. The thought is that bending your knees will shift the stress from the back to the knee, but this is not always true. Don’t get me wrong, you should always bend your knees when lifting, but there are other things that must be done as well.

To understand what you need to do to protect your back, you will first need to understand some basic bio mechanics. I promise to keep it very simple. You have 24 vertebrae sitting directly on top of one another that make up your spine. Your spine rests on top of a bone called the sacrum. The sacrum is positioned directly in between two bones called the pelvic bones. In between each of the 24 vertebrae and where the spine meets the sacrum is a disc which you have probably heard of before. While the vertebrae and the sacrum are bones, the discs are made of cartilage and fluid that is structurally not much different than a jelly doughnut; they are hard on the outside and soft in the middle.

Simply put, those vertebrae work together like a spring when you bend over. Imagine bending a spring back and forth over and over again. While that spring might be very strong at first, over time, it would weaken and eventually break. Most commonly with bending, the injury is to your disc. Imagine squeezing a jelly doughnut on one side, all the jelly would squirt out the other direction. This is a simplified example of a bulging or herniated disc. So how do we prevent this from happening?

The answer is very simple. Your back shouldn’t move. Your vertebrae shouldn’t be asked to bend on one another. Discs should not be squeezed on either side. The best way to prevent this is by bending from the hips and the knees at the same time. In case if you weren’t clear on where your hips are, they are the place where your legs attach to your pelvis. Run your hands down your sides, the first bone they come in contact with is the pelvis, as you continue to move your hands down towards your feet you will feel two large round bones, those are your hips. When lifting large, awkward objects from the floor, it is often advisable to drop to one knee in order to get the object off of the floor. For smaller objects or for objects that are located in an elevated position, bending at the hips and knees is advisable.

The first important point when lifting objects from below your hip height is the most simple. Stand close! I mean really close. You want the object that you are about to lift to be located as close to your legs as is possible. The closer the object is to your legs, the less it stresses your spine. Also, to avoid twisting, make sure whatever you are about to lift is directly in line with your belly button at all times.

Avoiding twisting when you lift...

Next comes the pelvic tilt. I give my patients a visual aide for this movement. You want to visualize yourself breaking a sheet of glass with your butt. Imagine that you are standing directly in front of a glass window, and you want to break it without bending your knees. You will have to thrust your butt backwards which will create a very stable arch in your low back. Once you have shifted your pelvis in this manner, your focus should be to continue to squat while reaching backwards with your butt as if you were hovering over a public toilet. Pairing the pelvic tilt with the squat will enable you to lock your lower back from any movement and thereby protect it from any injury! This will take practice to perfect, which is why I recommend to my patients that they practice the squat without weight daily.

So let’s recap. The first step in lifting an object is to stand close to it and make sure it is right in line with your belly button. The second step is tilt the pelvis forward to lock the low back. The third step is to squat while reaching your butt backwards the whole time as if hovering over a public toilet. If the object is too large or too low to squat down to, drop to a knee before lifting. My last piece of advice in regards to lifting is very easy to remember. If it’s too heavy, get help with it!

Every day people hurt themselves performing activities that should not cause them any pain or discomfort. If your form while performing these activities is perfect, you significantly reduce your likelihood of becoming one of these people. I recommend that you practice this technique a few times without any weight before you attempt to lift any objects in this manner. At first it will feel strange and unnatural. Give it time. You will quickly begin to take notice of how much better your low back is feeling, and you will be able to attribute that improvement directly to your new lifting technique. I wish you the best of success with this lifestyle change on your way to better health.

Forward any questions regarding this article to drsean@islandchiropractic.net

Dr. Sean Pastuch, D.C.

From the start...

Chiropracticstudent.org has hit a milestone today, just 3 days before the new year, the website banked a quarter million visitors for the year! Keep visiting and suggesting content!!

Here’s a little statistic sampling since our inception.

2009: 250,000 visits, 61000 unique

2008: 184,000 visits, 58000 unique

2007: 89,000 visits, 15000 unique

2006: 23,000 visits, 12800 unique

Think beyond the weight...

Well it’s that time of the year again. Time to take a look back at 2009 and review your successes and failures. What goals did you set out to achieve? How long did it take for those goals to be forgotten? What new year’s resolutions are you going to set out to achieve in 2010?

The holidays are a fantastic time of the year to review your successes and failures because it’s a time when we are reminded of the important things in life. Perhaps now is the best time to outline what goals are important to you and begin establishing a detailed plan to attain them.

I don’t like “New Year’s Resolutions”. Even the wording rubs me the wrong way. Why not call them “New Year’s Commitments”? Better yet, last year Chris Guillebeau from “The Art of Noncomformity” talked about the process of conducting your own annual review. According to Chris “The idea is to create a road map for the year ahead – not a rigid daily schedule, but an overall outline of what matters to me and what I hope to achieve in the next year.”

Unique to Chris’s annual review is the concept of having a yearly theme. You see when we choose goals like “Weight Loss” and “Get Rid of Debt” it limits us to only achieving weight loss and becoming debt-free. There are 3 things to consider when making your 2010 New Year’s Commitments.

1. Ensure a deeper meaning is attached:

What are you looking to achieve by losing weight and exercising more? What plan of action have you developed that systematically keeps you accountable, but also works in the context of your busy life? Having an annual theme gives a deeper context to your individual goals. If you fail to lose weight despite exercising more and eating better, perhaps now you recognize that you’re thinking more clearly and that you have more energy throughout the day. You still may be hobbled by consumer debt, but you’ve gained a greater consciousness of your monthly cashflow and perhaps you started a retirement account and put money there instead.

At the Wellness Solution Centers in Newtown, PA, chiropractors routinely provide a comprehensive physical examination that includes bloodwork, body fat analysis among numerous other measures. Initial examination takes 1 hour. Patients enter the office with the traditional goals of losing weight, but often find after an 8 week intensive program, their weight has not changed, and in some cases they have even gained weight. Now that the program has been up and running for a few years, patients now come in with goals to lower their blood pressure and improve their cholesterol and triglycerides. When they look at the full measure of their health through bloodwork and body fat analysis, they then realize that they have much more leaner tissue, less inflammation and are in fact much healthier than what they were when they arrived. Limiting your New Year’s Commitment to just one outcome measure causes one to monitor their status too frequently. Having a deeper theme to your goals will allow the completion of larger goals and keep your attention away from the small failures.

2. Individual goals may require completion of seemingly unrelated goals:

What’s been limiting you from taking action on your goals? Perhaps it’s a non-supportive relationship in your life. Perhaps its the stress of your job. Maybe it’s a lack of planning meals, or finding a time that allows you to go to the gym consistently. When it comes to health goals, many people take action in every way imaginable EXCEPT for the one actionable step they really need to take. Often times people will be chronically sick and spend every other week at their doctor’s office. Their goal may be to improve health, and they could exercise, follow-up appropriately with their doctor, but still eat McDonald’s once a day. It’s difficult to eat healthier at work, when you don’t prepare a meal ahead at home.

Our goals can very well be to lose weight, so as to improve deeper goals of self-image and confidence, but what if accomplishing that goal meant you needed to reevaluate how supportive your family and friends were? It’s difficult to take care of your debt when you hang out with high-spending friends with their parents’ credit card. It’s difficult to lose weight when those close to you are continually offering you sugary treats.

When you truly examine your goals appropriately, you have to dig deep to find the patterns behind those goals. You have to identify the root cause of the problem.

3. Inappropriate timeframe for completion of the goal:

I had a close family member approach me about a goal for weight loss. She exclaimed that she did not know what else she could do, she had been working out and eating better and had not seen any results. To figure out her problem, I had to only ask one question. “Well how long ago did you start?”. She responded “Two weeks ago”.

We live in an information age full of short soundbytes and bulleted lists. To lose weight healthily, you should look to only a few pounds a month of weight loss. When you focus on short-term gains and losses, your consistency becomes short-term.

My theme for 2009 was gratitude. It brought me a beautiful girlfriend, less stress at school and closer and more authentic relationships with family and friends. My theme for 2010 is “following through”. I’ve found that I start projects but leave them half-finished. So many great projects are left unfinished just when they approach the brink of greatness. I assure you 2010 will be different.

So now that you’ve had some time to think about it…what’s your annual theme for 2010?

Is the risk real?

Chiropractic is the largest alternative medicine profession in the United States, and probably the most debated. Undeniably, the hottest debated topic concerning chiropractic is stroke risk. But are you really flirting with death when you visit a Chiropractor? This article, written with common argument headers, attempts to discern if cervical manipulation is a risky treatment, especially when compared with other popular treatment options.

Neck manipulation dissects the vertebral basilar artery leading to stroke…

The most basic argument that needs to be proven for anti-manipulation activists to have a ground to stand on is whether a neck manipulation has the physical means to cause a stroke. Detractors claim that forceful manipulation of the neck dissects the vertebral basilar artery, which passes through the atlas (top neck bone/vertebrae) before it enters the skull. This dissection is caused by either the physical stretching of the artery or by its contact with the bone. This very idea is actually what many chiropractic colleges teach, but its reality becomes doubtful when viewing the research.

A series of studies were conducted to determine how much force and stretch the vertebral artery can sustain before it fails. Symons study, using cadavers, applied multi-directional forces to the the neck while measuring its effects on the vertebral artery. It was determined that the arteries could withstand stretching between 132% and 160% their normal length before failing. The study was repeated utilizing cervical manipulation techniques, and it was found that the vertebral arteries were maximally stretched by 6.2% their resting length (Symons 2002). Even more interesting was although cervical manipulation is often perceived as inducing large amounts of neck rotation, due to its controlled nature the vertebral arteries are actually stretched less than in normal neck range of motion (12.5% max).

The idea that the problem is a disruption of blood flow is also not supported by the literature. Licht et al performed a study in which vascular flow was monitored pre and post adjustment. There was no difference between either groups.

Further proof that cervical manipulation is unlikely to cause vertebral artery dissection can be seen when you compare it to motor vehicle accidents. Although MVAs are a traumatic event linked to many health complications, stroke is not one of the commonly associated events. Studies measuring the force of an MVA on the neck demonstrated peak forces of about 241 Newtons, while studies focusing on forces of neck manipulation show a maximal force of 93 newtons. On top of that, rotatory forces maxed out at only 50 newtons (Haneline 2005) If the greater force seen in an MVA fails to cause strokes, why would a lower force adjustment cause it?

The number one cause of cervical arterial dissections are idiopathic. In other words, doctors have no idea what has caused it and thus it is considered spontaneous and unpredictable. Spontaneous Vertebral artery dissections occur at a frequency of about 1 per 100,000 people in the general public (Haneline 2007). Which is an eye opening statistic when the chiropractic population experiencing a CAD is believed to be about 1 per 100,000 patient, which would mean chiropractic patients are at no greater risk for stroke than the general population.

This neurology study showed that stroke occurred after adjustments…

Probably the most cited research article by neck manipulation detractors is a Canadian population based case-study by Rothwell (2001). The study demonstrated that patients who had a stroke were 5 times more likely to have seen a chiropractor within the previous week, and is a perfect example of correlation, but not causation. One key variable that the study had failed to address was why the stroke patients had visited a chiropractor in the first place. Unfortunately, many of the symptoms of a stroke are the same as the reasons people see Chiropractors: neck pain, headaches, tingling or numbness in the extremities, and occasionally mild dizziness. Strokes also present with more pathognomonic warning signs, but these signs tend to be rare, such as severe dizziness, nausea, vomiting, abnormal gait, trouble speaking, and loss of vision in one of the eyes (AHA 2009). Also, the demographic group most prone to idiopathic strokes are also the Chiropractors biggest patient base, young to middle aged women with no major health concerns.

Anti-Chiropractic bias also appears to taint many cervical adjustment articles. One key example is an article in the Journal of Neurology entitled “Vertebral Artery Dissections after chiropractic neck manipulation in Germany over three years.” Not only was this study, like Rothwell’s, a purely correlative study with no modification for external variables such as presentation, but the study’s title unfairly targets Chiropractors. Analysis of the data shows that 11% of all strokes recorded were performed by chiropractors, while 50% were performed by orthopedic surgeons and 14% by physical therapists (Rueter 2006). Even though the manipulations by MD’s and PT’s had a higher rate of associated stroke, it is the Chiropractic Adjustment that is dangerous.

Finally, recent reports have shown that an elevated incidence of stroke is seen equally in Chiropractic and medical physician offices (Cassidy 2008); once again supporting the theory that patients are presenting with a stroke, and not that DC’s, or MD’s for that matter are causing a stroke.

A signature isn't enough.

Chiropractors don’t inform patients of the risk…

A rare valid argument. Some chiropractors do not inform patients that there is a risk for stroke, others do have it written in their informed consents but fail to verbally state it (who reads those things anyway?) Legally, Chiropractors are not required to inform patients of the risk for stroke because the odds of one are so low. However, informed consent should not merely be a Risk Ratio, but also a Perceived Risk-Ratio (Ziker 2003). Since the risk of stroke is perceived in chiropractic, the doctors should address it, regardless if the risk is real or not.

I read a case study in which the person had a stroke…

We’ve all seen the case reports or the news stories where someone immediately suffered a stroke right after receiving an adjustment. However why the stroke happens presents us with three options.

1. The doctor’s impulse caused a stroke in an otherwise healthy patient. Not possible, as the prior argument has already established.
2. The patient was a stroke waiting to happen. The adjustment was the final straw. This is the most likely situation. As noted prior many patients who are currently in a stroke status may visit a chiropractor for their symptoms. In this case, any minute trauma may either mobilize a clot or cause the artery to dissect. Whether or not the doctor should be held responsible in this situation really depends on the circumstances. An unfortunate reality is that there are currently no known reliable orthopedic or neurological tests for stroke (although the Newton Neurological Battery looks promising). The best tool a doctor has is a thorough complaint history and the presentation of the pathognomonic signs. When a patient presents with the hallmark red flags, the doctor should send the patient to the hospital immediately.
3. The patient suffers an idiopathic stroke unrelated to the adjustment. Pure dumb luck.

The risk outweighs the benefits…

The rate of stroke associated with cervical manipulation varies widely among the literature. Figures place the occurrence at as often as 1 in 400,000 cervical adjustments (Dvorak, 1985) and up to 1 in 5,850,000 cervical adjustments (Hosek, 1981). Currently the generally accepted odds are about 1 in 1,000,000 to 3,000,000 cervical adjustments (Lauretti 1997); the RAND report, which is the document most federal mandates concerning chiropractic effectiveness is based upon, also puts the risk at about 1 in a million. However, there is an inherent problem within all manipulation risk studies, in that they are based on correlations, and none are experimental or direct causation models. One of the oldest tenets of research is that correlation does not equal causation. For example, there are an increase in armed robberies when ice cream sales increase. Of course its ludicrous to say that ice cream cause robberies, and instead there must be other variables in play. In this case, robberies increase during the summer, which is the same time ice cream sales increase.

For the sake of our argument, we will be using the 1 in 1,000,000 estimate, and I will compare it to the serious risks associated with other common treatments for neck pain and neck related conditions, all of which are considered safe alternatives. Serious risks are defined as those requiring medical attention.

No treatment is without its risk.

NSAIDS (Aspirin, Aleve, Ibuprofen, etc…) One key meta-analysis using 18 studies published between 1990 and 1999 assessed the risk of life threating upper gastric complications (bleeding, perforation, and hospitalization) when confounding variables such as age, previous complaints, and other medications were removed. It was found that individuals taking NSAIDs (ibuprofen, naproxen “Aleve”, etc…) were at a 380% increased risk of a serious upper GI complication (Hernandez 2000). Mathematically, if you take NSAIDs that equates to the odds of 3500 per million of having a serious upper gastrointestinal condition.

Another study focused on the risk of selective inhibitor anti-inflammatory drugs, such as COX-2 which is designed to prevent GI complications, was analyzed for myocardial infarctions (heart attacks). It was found the relative risk for these drugs are 24% higher than the standard population (Levesque 2005). Adding fuel to the fire, and resulting in the lost license of two major NSAID medications, a Medicare database study after removing most confounding variables, determined that serious cardiovascular complications resulted about 4.1% of the time when taking NSAIDS, including Aspirin (Solomon 2008). What are serious cardiovascular complications? Heart attack, stroke, congestive heart failure, and death. Other studies take these findings ever further claiming drugs such as aspirin, may actually increase the risk of heart attack up to 71%, with an average risk of about 12% (EULAR 2005). Taking the average, this could mean that an additional 570 people suffer NSAID induced heart attacks a year.

Acetaminophen (Tylenol, Excedrin, etc…) The good news with Tylenol is that it is not associated with cardiovascular or gastrointestinal disorders. However, that doesn’t mean its off the hook. Acetaminophen is associated with liver damage, and according to the FDA it is the number 1 cause of acute liver failure in the United States. Usually this is associated with over-dosage, but even minimal usage over the recommend dose is associated with death. This is especially a concern because many people will double or triple their dosages when they are in a lot of pain. Acetaminophen is the cause of 56,000 emergency room visits and 458 deaths a year (FDA 2009). The drug has also been indicated in kidney failure, as an article published in the New England Journal of Medicine determined that regular acetaminophen or aspirin usage put users at 2.5 times the risk for kidney failure, or 250% (Fored 2001). The general public sees about 1550 per million in end stage kidney failure, so if you overuse Tylenol, your odds become 3875 per million. In all fairness, this was a correlative study, not causative. (Coresh 2007)

Neck Surgery Neck and arm pain, tingling, and numbness are often the result of cervical disk herniations, stenosis, and spondylosis; all conditions that are treated with chiropractic. However, if diagnosed in an allopathic office, patients are often recommended for surgery. Although frequently uneventful, surgery obviously has its own risks. One study assessed the complication rate of cervical spine fusion for primarily the noted above conditions (Wang 2007). It was found that 0.83% of all surgeries are associated with a serious complication: Cord injury, artery dissection, infection, cardiovascular comprise, respiratory distress, nerve damage, and death. Therefore, for every 1 million cervical fusion surgeries, 8300 result in serious complications . Once again in all fairness, surgery will often involve the most serious cases and therefore their odds for complication should be elevated.

Physical Therapy & Exercise Serious complications associated with physical therapy are almost as difficult to determine as they are in chiropractic care. Most likely stroke risk matches that of the general population and initial cardiovascular risk may be somewhat increased due to increased physical load, but should decrease over extended treatments due to improving physical health.

Table 1

Conclusions

Compared to the risks associated with the most commonly used treatments for neck pain, it becomes clear that chiropractic neck adjustments are at the very least, comparatively safe. In fact, you are more likely  to die while driving to the doctor’s office in an auto accident than at the hands of the doctor. Furthermore, current research fails to even demonstrate a physiological or anatomical means for a chiropractic adjustment to induce a stroke in healthy patients. Therefore research and debate should begin to move away from attempting to determine if adjustments are safe, and move towards ways to increase the effectiveness of adjustments and improved methods of detecting the small at risk populations.

In closing, a little perspective…

By Kristopher Robert Schuster, D.C., B.S.

Note: There is a poll embedded within this post, please visit the site to participate in this post's poll.

References

1.AmericanHeart Association. Stroke warning signs. Retrieved from http://www.americanheart.org/presenter.jhtml?identifier=4742 on November 20, 2009.
2.American Heart Association. Heart attack and angina statistics. Retrieved from http://www.americanheart.org/presenter.jhtml?identifier=4591 on November 20, 2009. 3.Cassidy JD, Boyle E, Cote P, He Y, Hogg-Johnson S, Silver F, Bondy SJ. Risk of vertebrobasilar stroke and chiropractic care: Results of a population-based case-control and case-crossover study. Spine 2008; 33 (4S):S176-S183.
4.Coresh, J, Selvin, E., Stevens, L.A., et. al. (2007). Prevalence of Chronic Kidney Disease in the United States. J American Medical Association, 298(17), 2038-47.
5.Dvorak J., Orelli F.V. (1985) How dangerous is manipulation to the cervical spine? Manual Med. 2(1), 1–4.
6.European League Against Rheumatism (2005). Retrieved from http://www.theheart.org/article/502645.do on Nov19, 2009.
7.FDA Eyes Acetaminophen Liver Risks (2009). Retrieved from http://www.webmd.com/news/20090528/fda-eyes-acetaminophen-liver-risk on Nov19, 09.
8.Fored, C.M., Ejerblad, E. Lindblad, P., et. al. (2001). Acetaminophen, Asprin, and Chronic Renal Failure. New England Journal of Medicine, 345(25), 1801-1802.
9.Haneline M, Triano J. (2005). Cervical artery dissection. A comparison of highly dynamic mechanisms: manipulation versus motor vehicle collision. J Manipulative Physiol Therapy, 28(1), 57-63.
10.Haneline, M.T., Rosner, A.L. (2007). The etiology of cervical artery dissection. J Chiropractic Medicine, 6(3), 110–20.
11.Hernandez-Diaz, S., Rodriguez, L.A., (2000). Association between nonsterodial anti-inflammatory drugs and upper gastrointestinal bleeding/perforation. An overview of epidemiological studies published in the 1990s. Archives of Internal Medicine, 160, 2093-99.
12.Hernandez-Diaz, S., Rodriguez, L.A., (2002). Incident of serious upper gastrointestinal bleeding/perforation in the general population: review of epidemiologic studies. Journal of Clinical Epidemiology, 55, 157-63.
13.Hosek, R.S., Schram, S.B., Silverman, H., Myers, J.B., Williams, S.E. (1981). Cervical manipulation. J American Medical Association. 245(9), 922.
14.Lauretti, W.J. (1997). Retrieved from http://www.chiro.org/chimages/chiropage/cva-1.html on November 20, 2009.
15.Levesque, L.E., Brophy, J.M., Zhang, B. (2005). The Risk for Myocardial Infarction with Cyclooxygenase-2 Inhibitors: A Population Study of Elderly Adults. Annals of Internal Medicine, 142(7), 481-89.
16.National Safety Council (2004). Odds of dying. http://www.nsc.org/lrs/statinfo/odds.htm
17.Rothwell D.M., Bondy S.J., Williams J.I. (2001). Chiropractic manipulation and stroke: a population-based case-control study. Stroke, 32,1054-60.
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That makes it critical, both for patient safety, and our professions reputation to establish methods to detect a stroke patient before any manipulation is provided. In the past, orthopedic tests have been notoriously inaccurate (Drift Test, George’s, etc..) and thus many doctors do not even use them. To date, our best indicator was the patient’s presenting history.

But in addition to a proper history, a new serious of neurological bedside tests finally provide some solid clinical data. Dr. David Newman-Toker recently presented a short series of examinations that proved to be 100% sensitive and 96% specific. Of course further testing needs to be done, as this was a single center study of high risk patients, but regardless it is quite promising.

Newman’s tests included:

1. Strong Horizontal head impulse (a normal patient & a stroke patient’s eyes stays stable during the impulse, an inner ear complication would result in an ‘eye flick’).
2. Nystagmus (Lateral in the same direction as the patient is looking, occurs when the patient looks in either direction)
3. Downward alignment of the eyes when one is rapidly covered and uncovered.

As I research continues on this subject I will update this article.

View the demonstration here… http://www.medscape.com/viewarticle/710698 (you may be required to sign up to view it).

1. Join Profession Organizations! I can’t stress this one enough. When I was leaving my undergraduate school, Valparaiso University (Great school… I know shameless plug), my Uncle told me that the single best piece of advice he could offer is to join societies. They are absolutely invaluable in establishing contacts and networks. Within a two weeks of joining one of the state chiropractic organizations, I had 4 good interviews lined up.
2. Network with influential doctors. I’ve been regularly shadowing doctors who are board members of their state associations and chiropractic licensure boards, talk about some good contacts.
3. Make a cover letter! Many people forget this critical element to a resume. Its your chance to show your personality and appear different from the pack.
4. Know what you want. Most Doctors want an associate who have goals and drive. In every interview I’ve had I’ve been asked where do you see yourself in 5 years. If you don’t know, your likely not as driven as the Doctor would like, and if you appear unsure in your answer, it will show.
5. Trust your Gut. If red flags go off, don’t take the job, but be polite in your denial; you don’t want to burn any bridges.
6. Send Thank You Letters… Immediately. This shows the doctor that your on the ball, value their time, and really want the job.
7. Spell Check Spell Check Spell Check. If you cant get the detail’s right onn the most important document of you’re life, why would you be anymore caerful with anything else;
8. Be honest. Don’t fudge your resume, or try to be someone you’re not in the interview. Most likely it will show, and if it does not you could find your self in a job you don’t like or are not qualified for.
9. Don’t forget that this is a business. In the interview, show the Doctor how you will help his practice become more successful.
10. Ask lots of questions. Probably my biggest failure. Asking questions shows you are paying attention and are genuinely interested.
11. Post a classified. There are many sites where you can place free ads, such as this website and planet chiropractic.

This article is a growing piece and work in progress. If you have anymore tips please comment, especially if you are a Doctor who has hired in the past.

Is it really worth it?

Discography, a painful imaging technique for the spine that involves the injection of a contrast medium, has long been debated for its efficacy and utility(1,2,3). Even though it has been around since 1948, research to this day still fails to establish Discography as a effective test. It has been suggested that it is an accurate test for only a minute group of conditions, while it is unreliable for disk degeneration, disk bulges and protrusions, as it lacks specificity and leads to unnecessary back surgery (4). Regardless, this procedure is still sees widespread usage as doctors argue it is better than MRI or CT.

New research published in Spine, decided to take a different role, and examine the risks to benefits ratio of a discography. In their experimental animal model, it was shown that the rats that received small needle punctures exhibited a significantly higher rate of herniation, endplate changes, disc grade progression and annular fissures; both in frequency and severity. They also demonstrated a statistically significant decrease in disk height and signal after the injection (5).

Dr. Carragee et al.’s study brings up serious concerns with the usage of discography. Why countinue to utilize a technique that has been so poorly proven to provide usable & correct clinical data, and that also causes what you are attempting to locate and fix. It appears that this is a classic case of Risks far outweighing the benefits.

For a further information on Discography, and a slightly more pro-discography viewpoint, eMedicince provides a good overview.

Sources

1. Derby R, Howard MW, Grant JM, et al. The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Spine. Feb 15 1999;24(4):364-71; discussion 371-2

2. Parker LM, Murrell SE, Boden SD, Horton WC. The outcome of posterolateral fusion in highly selected patients with discogenic low back pain. Spine. Aug 15 1996;21(16):1909-16; discussion 1916-7.

3. Knox BD, Chapman TM. Anterior lumbar interbody fusion for discogram concordant pain. J Spinal Disord. Jun 1993;6(3):242-4.

4. Nachemson A. Lumbar discography–where are we today? Spine. Jun 1989;14(6):555-7

5. Eugene J. Carragee, MD; Angus S. Don, FRACS; Eric L. Hurwitz, DC, PhD; Jason M. Cuellar, MD, PhD; John Carrino, MD; Richard Herzog, MD