Posts Tagged ‘posterior facet syndrome’

Could Chiropractic prevent some cases of osteoarthritis – seems so.

Tuesday, January 5th, 2010

Rupert Clements, one of the chiros @ C1 writes about a powerful study showing a clear link between a lack of motion in the spinal joints and the development of osteoarthritis.

An interesting study was carried out by G.Cramer, J.Fournier, et al. in October last year titled:

Degenerative Changes Following Spinal Fixation in a Small Animal Model.

It was then published in the Journal of Manipulative and Physiological Therapeutics, Vol. 27 No. 3, Pgs. 141-154

The study evaluated changes in the small joints, the facet joints, of the lumbar spine after they were artificially fixed together and therefore prevented from moving.

LUMBAR facet JOINT Could Chiropractic prevent some cases of osteoarthritis seems so.

The study used an established small animal (rat) model of spinal fixation (hypomobility) where 3 contiguous lumbar segments (L4, L5, L6) were fixed with a specially engineered vertebral fixation device. Spinal segments of control rats were compared with those of animals whose spines had been fixed for 1, 4, or 8 weeks. Subgroups of these fixation animals subsequently had the fixation device removed for 1, 2, 4, 8, or 12 weeks to evaluate the effects of attempting to re-establish normal forces to the vertebral segments following hypomobility. The joints that were fixated were examined microscopically to determine how the lack of motion affected the health of the joints. By using small animals such as mice or rats, the changes they go through in a study can be very closely observed in a way that, clearly, they can’t be in human studies.

The conclusion: These findings indicate that fixation (hypomobility) results in time-dependent degenerative changes of the Z joints (the small facet joints in the spine).

The study was a high quality study which produced some highly meaningful information.

So, what did they find? The joints that were immobilized began to break down and degenerate, while the joints that moved remained healthy. The type of breakdown that the researchers found in the fixated joints was the same as in osteoarthritis; which is the most common type of arthritis and while there are many types of arthritis, this is the type people are generally referring to when they say ‘arthritis’. They also found that the longer the joint did not move the more degenerative arthritic changes it showed. The point is that this reflects the same processes that occur in you and I and that is why it is so valuable.

So who do I pass this on to? Anyone who mentions suffering from, or wanting to avoid, arthritis. Or better yet, pass it on to the person you know who is already very health conscious, wants to stay active, and wants to learn how chiropractic care can help keep them moving and healthy!

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Posterior Facet Syndrome – what is it and can chiropractic help?

Friday, August 21st, 2009

Posterior Facet Syndrome – an injury of the joints in the back

I’ve had a hell of a day explaining to a very important lawyer why his back is hurting him. He has had a hell of a day refusing to hear what I have said and done, even though I’ve allowed him to stand upright for the first time in a few days (I suspect this is because he’s in the thrall of his denialist shrew of a wife).

However, the thrust of what I was banging on about is this:
Firstly, where are these Posterior Facet Joint things? The facet joints, or incredibly the zygapophyseal joints, are the relatively small joints on the outside of the bridge of bone that protects your spinal cord. They control the range of motion available at each level of the spine and you have them at every level. However, they do look different as you move up or down your spine, because ‘form follows function’ and they have to do different jobs in different parts of your spine- see?

Each joint, like most joints, is enclosed in a joint capsule which is a complex structure that provides feedback to the brain about the state of the joint, as well as a host of other tasks such as supplying synovial fluid to the joint space as well as some joint stability. Research has shown that in the low-back there can be a ‘meniscoid’ structure in the joint space, just like a mini version of the meniscus in the knee joint.
So that’s what the thing is like. Now what can go wrong?

Posterior Facet Syndrome (PFS). Contrary to what the physios may say this is a hugely prevalent problem and is, arguably, our bread and butter. It is a syndrome because the injury it involves far more than one structure and a whole raft of unpleasant things can go on.

In a severe, acute, PFS there may be some injury to the faces of the joint but rarely. There have also been several theories put forward about some nipping of the joint capsule or the meniscoid tissue between the two bones. However, there will certainly be some sprain/strain of the very sensitive structures of the capsule, the surrounding micro-ligaments and local muscles. Your body will rightly respond to this injury by stabilising the joint with whatever it can – in this case it will be the surrounding muscles and in the low-back these muscles are really powerful.

Your brain can stabilise your back very quickly and is why you will have seen people bending over and suddenly being unable to move or coming into work unable to move their heads. What your brain does is sacrifice these powerful muscles in favour of the PF joints and force the muscles to remain contracted for as long as required. Now, try holding a weight in your flexed arm for any length of time and you’ll see how painful this continued contraction can be. This is the same thing that is going on in your back BUT the contraction will be even stronger as it has to hold your body still and so far more painful. Also, your brain will not turn these stabilising muscles off until the problem is resolved and nor should you – so no early massage madness and NO MUSCLE RELAXANTS (aaahhhhh).

PFS will really sting. In a severe acute phase you may not be able walk and when I did mine after a rowing session I had to remain still until I was driven to stand by my bladder that was about to explode and even then I nearly passed out. The structures that hurt were the injured joint capsule; this will be the white hot sharp pain, and then the large paraspinal muscles that my body had wisely recruited in to span the joint like scaffolding which was a deeper burning pain.

As with trauma to any joint, such as spraining an ankle, there will be an inflammatory reaction with loads of swelling and pain around the joint, which may last for several days. This may also irritate the spinal nerves that pass out of the spine at this point and you may get a referred pain. Typically, this will be less defined and usually a burning pain. To check if your pain is a referred pain give the area a gently prod and if you can’t get a finger on a pain generating structure then, as a rule of thumb, it’ll be a referred pain (clear?). Please don’t call it sciatica unless you are still using terms like lumbago and ague as sciatica is a description of pain along the sciatic nerve distribution which goes far further than the hip and groin.

Typically, you’ll find back pain just to one side of the spine in the paraspinal muscles that are stabilising the joint. Side bending toward the affected side or backward bending will compress the facet joint faces together and make the pain worse – some physios find this concept a challenges as they tend to be muscle focused. The back will generally feel stiff in the morning as a post inflammatory response. Often the problem is made worse by prolonged sitting or standing in one position as the joints get compressed and start to sing.

What causes PFS?
A severe acute episode of PFS pain may be due to sudden, aberrant, movement, which traumatises the joint such as the classic lifting injury as a result of poor core stability. More commonly PFS is chronic with the underlying cause due to long term changes in the joint that are often again associated with poor core stability, wear and tear and poor posture.

What you can do?

Ice – it’s an inflammatory issue at heart so DON’T heat it up. If you listen to the stabilising muscles you will hear them shouting for heat as this is a muscle injury but the contraction is intentional and unless you have torn these in the initial injury (unlikely) you must ignore the cry. Get this wrong with an ankle joint and it can extend the time to recover by up to 5 times and I’d suggest that PFS is an ankle sprain/strain of the back joints and so the same thing will happen – so no hot baths, please.

It may be worth taking some non-steroidal anti-inflammatory (NSAIDs) with all the risks associated with these things.

“Get thee to a chiropractor” who will manipulate the joint with a controlled thrust to reduce the compression, restore correct movement and so reduce inflammation and pain.

DO NOT heat it up until much later. DO NOT wear a brace.

However, what I found on the web!
This: “In a more chronic type of Facet joint problem, the management is more difficult. The treatment outlined above will usually be attempted first, with the Chartered Physiotherapist giving symptomatic relief of the stiffness using heat packs and mobilisation techniques. However, where there is persistent pain originating from a Facet joint problem, this has to be addressed. An injection of long acting local anaesthetic and anti-inflammatory corticosteroid into the Facet joint may be effective in relieving symptoms and, if successful, it confirms the diagnosis. In order for this approach to work the injection is best done by a Consultant Radiologist under an image intensifier. This device allows the doctor to see exactly where the injection is going. This approach can give very good pain relief, but the effects may wear off after a while. It may be necessary to repeat the procedure at a later date.”
Good grief! all that radiation and then some powerful steroids when all it really needed was a dose of ice and some decent care. Try anything else first, please.

And then:
“In cases of Facet Syndrome that cause constant unremitting pain, a more lasting approach for pain relief is a procedure known as ‘Radiofrequency denervation’. Radiofrequency denervation is a technique where the nerves that supply the Facet joint are destroyed by ionizing radiation rather than surgery. This is effective for the relief of pain, but will not stop or reverse the underlying joint degeneration.”
Killing nerves! Can this really work?

The evidence from NICE and MEADE and others is that chiropractic and other manipulative therapies are the way forward. Give it a go and see what I mean.

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Can Chiropractic help with neck pain?

Wednesday, August 19th, 2009

We’ve had a recent rush of patients coming in with neck pain – something to do with added work stress, perhaps? I was irritated by how vague we are on neck pain and how difficult it was to describe in effective ‘lay’ (but not patronising) terms what the hell was going on. And this got me thinking….

How common is neck pain?
Well, you are certainly not alone – Hill and co-workers report that in the UK many as 31% of adults have had neck pain in the last month (the adult population of the UK has got to be over 50 million people so, as hey say in the US, “Go do the math”) and 48% of neck pain patients report persistent pain a year later.
- Hill J, Lewis M et al. (2004) Predicting Persistent Neck Pain. Spine 29:1648-1654

What’s going wrong?
Well, this is trickier. Liebenson, Skaggs et al. say that it is ‘difficult to pinpoint the specific pain-generating tissue’ of neck pain and even if you can the reasons why ‘are often elusive’. Now, in my experience the most common neck problem we see is ‘Posterior Facet Syndrome’, one of the mechanical neck pains, and it is caused by compression of the facet joints as a result of anterior head carriage commonly aggravated by peering into the computer for eight hours a day.

Though, try Googleing ‘Posterior Facet Syndrome’ and see what comes up as it is a hotly debated subject with some denialists saying it doesn’t exist though how can this be as I treat it daily and it responds very well.

In trying to describle what I am treating I say that PFS is similar to an ankle sprain but of the neck joints and that, like an ankle sprain, a whole raft of different tissues may be involved in the injury depending on how it was done. This seems pretty plausible to me and covers all the bases and, as long as we are treating these tissues, we should have some impact on the problem – yes?

There are some even stranger things happening out there in neck land. Up to 71% of patients who have chronic pain following whiplash have undetected vertebral end plate fractures at the spinal levels associated with the pain that were overlooked on standard medical imaging.
- Michael Freedman Dec 2001.
Not surprisingly, I suspect that this has some impact on the way things progress in a neck but, surprisingly, there may well be nothing that can be done about it and that even if the information was available it would not change the way the neck was managed anyway.

Neck pan can be split into these broad categories:

Grade 1 – neck pain with little or no interference with daily activity.
Grade 2 – limits daily activity.
Grade 3 – neck pain with accompanied radiculopathy (pinched nerve pain, weakness and/or numbness in the arm)
Grade 4 – neck pain with serious pathology – tumour, infection or systemic disease.

(Clearly, along with mechanical neck pain there are some real nasties out there; neck pain may be a symptom of meningitis and if any of the following symptoms occur, dial 999 or seek medical attention urgently:
• A rash develops that does not fade when you press it with a glass tumbler or a finger.
• You feel ill or are running a fever as well as feeling neck pain.
• It is to painful to bend the neck forward and put your chin on your chest.
• Light hurts.
• Your neck pain is accompanied by severe headache or continuous vomiting.
• Neck pain is accompanied by severe pain in the back.
And in some cases, neck pain can be a symptom of head injury or disc trouble in the neck, so. If any of the following symptoms occur, dial 999 or seek medical attention urgently:
• Neck pain is the result of a recent head injury and you are becoming drowsy, confused or are vomiting.
• Neck pain is accompanied by headache.
• If there is pain behind one eye.
• Vision, hearing, taste or balance are affected.
• Severe vomiting.
• The muscle power in your arms or legs is reduced.)
Treatment
Here’s the science bit:
Cleland et al. showed that manipulation of the thoracic spine produces immediate analgesic effects in patients with mechanical neck pain.
- Cleland JA, Childs JD et al. (2005) Immediate Effects of Thoracic Manipulation in Patients with Neck Pain: A Randomized Clinical Trail, Manipulative Therapy 10:127-135.
And Liebenson recommends manual therapy with some rehabilitation exercises. This has been supported by one of the strongest research trials in this field carried out by Bronfort, Evans et al. In this trial 191 patients were split into three treatment groups, like this:
• Spinal manipulation and low-tech exercise,
• Spinal manipulation and MedX exercise – receiving dynamic progressive resistance exercises on MedX machines,
• Spinal manipulation.
Outcomes were measured at 5 and 11 weeks and 3, 6 and 12 months after the trial. At the one year follow up the group that were receiving exercises and manipulation did significantly better than the group undergoing manipulation alone.

In a literature review published by Hurwitz, Aker et al. in Spine and Aker, Gross et al. in the British Medical Journal, so hardly slack journals I’d suggest, manipulation and mobilization were both more effective than muscle relaxants and usual medical care in providing pain relief for patients with sub-acute or chronic neck pain. In a study (2003) in Spine Giles and Muller compared acupuncture, joint manipulation and standard medication (NSAIDs). Patients in the acupuncture and medications groups had no significant improvement during the trial on any of the outcome measures and the manipulation group showed significant improvement on all measures with no patient made worse or experiencing side effects. Giles and Muller then followed up their patients a year later and reported that the manipulation group gained ‘significant broad-based beneficial…long-term outcomes’ (I like Giles and Muller).

In a great study by Haneline at Palmer College of Chiropractic, 79% of the patients improved to the point they had only minimal or minor restriction of movement and their satisfaction rates were an astounding 94% – and I suspect few trials can report the same, with 70% indicating they were very satisfied. When asked which provider helped the most 83% replied the chiropractor (this all sounds too much like a dodgy ‘election’ in North Korea for it to sit comfortably with me but….)

However, and there’s always one, here’s what the GP’s advise on http://www.patient.co.uk/:

Exercise your neck and keep active
Aim to keep your neck moving as normally as possible. At first the pain may be quite bad, and you may need to rest for a day or so. However, gently exercise the neck as soon as you are able. You should not let it ’stiffen up’. Gradually try to increase the range of the neck movements. Every few hours gently move the neck in each direction. Do this several times a day. As far as possible, continue with normal activities.
In the past, some people have worn a neck collar for long periods when a bout of neck pain developed. The problem with collars is that they prevent you from moving your neck properly. Studies have shown that you are more likely to make a quicker recovery if you do regular neck exercises, and keep your neck active rather than resting it for long periods in a collar. Also, if you keep the neck active during a bout of neck pain, it is thought to help prevent chronic (persistent) neck pain from developing.

(So good, reasonable advice so far but then…)

Medicines
Painkillers are often helpful. It is best to take painkillers regularly until the pain eases. This is better than taking them now and again just when the pain is very bad. If you take them regularly, it may prevent the pain from getting severe, and enable you to exercise and keep your neck active.
• Paracetamol at full strength is often sufficient. For an adult this is two 500 mg tablets, four times a day.
• Anti-inflammatory painkillers. Some people find that these work better than paracetamol. They include ibuprofen which you can buy at pharmacies or get on prescription. Other types such as diclofenac, naproxen, or tolfenamic need a prescription. Some people with asthma, high blood pressure, kidney failure, or heart failure may not be able to take anti-inflammatory painkillers.
• A stronger painkiller such as codeine is an option if anti-inflammatories do not suit or do not work well. Codeine is often taken in addition to paracetamol. Constipation is a common side-effect from codeine. To prevent constipation, have lots to drink and eat foods with plenty of fibre.
• A muscle relaxant such as diazepam is sometimes prescribed for a few days if your neck muscles become tense and make the pain worse.
(Awww, and they were doing so well. The problem in your neck has nothing to do with a lack of pain-killer in your blood so don’t do it. The evidence doesn’t support it so why advise it unless there is some other reason and I am not going to suggest that we are a drug reliant NHS, oh no. I will suggest that the muscle tightness has a purpose and is not a trick that your neck is doing just to irritate you, perhaps; just perhaps, your brain wants to immobilize the injured joints, just like an ankle sprain then, and is using the muscles surrounding the joint to do this. So why would you want to take a muscle relaxant to stop this happening, why would you want to over ride your clearly stupid brain and let your neck move freely during an acute phase?)
Other advice
Some other advice which is commonly given includes:
• A good posture may help. Brace your shoulders slightly backwards, and walk ‘like a model’. Try not to stoop when you sit at a desk. Sit upright.
• A firm supporting pillow seems to help some people when sleeping.
• Physiotherapy. It is not clear whether this makes much difference to the outcome of mechanical neck pain. Therapies such as traction, heat, cold, manipulation, etc, may be tried, but the evidence that these help is not strong. However, what is often helpful is the advice a physiotherapist can give on neck exercises to do at home. A common situation is for a doctor to advise on painkillers and gentle neck exercises. If symptoms do not begin to settle over a week or so, you may then be referred to a physiotherapist to help with pain relief and for advice on specific neck exercises.
So, manipulation gets one word. Yet the recent report from the Bone and Joint Decade 2000 – 2010 Task Force on Neck Pain and Its Associated Disorders (made up by a staggering 50 researchers in 9 countries comprising of 14 different clinical disciplines and looking at over 31,000 research criterion and over 1000 met relevant criteria.) recommended that neck manipulation, acupuncture and massage are better choices for managing most common neck pain. It also recommended exercises, education and neck mobilization but to be less effective than adjustment.

I know which one I’d chose.

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‘Trapped nerve’: what sort of junk diagnosis is that?

Thursday, July 30th, 2009

Agggghhhhh, so another utterly cod diagnosis arrives on my mat. A friend’s son is ‘diagnosed’ with a trapped nerve. He is 8 and has pain on extension, flexion and rotation but the pain is localised and really, really nasty and with some epic muscle tightness in his lumbar region.

After a bit of questioning it is bloody obvious that he’s got a posterior facet syndrome which with a bit of care and a load of ice will come good fast – which it does and he’s ready to climb a Welsh mountain a few days later.

But it got me fuming about ‘trapped nerves’ and what an utterly piss-poor diagnosis this is, it sits up there with lumbago and ague as a really lazy bit of work. Now, I admit a nerve entrapment is entirely possible – just google entrapment neuropathy and you’ll get some real spot-on diagnosis such as medial plantar neuritis and thoracic outlet syndrome. These nerve entrapments are crackers and really obvious and clear cut once you are thinking right. However, to achieve the same sort of thing in your lumbar region is a far, far trickier thing.

Consider the anatomy and what you’d have to do to pinch or trap a nerve. The most simple to imagine would be a classic disc herniation or prolapse, the bulge in lay-terms. Now this can compress the nerve root in the back but these are rare, have a raft of pretty convincing signs and symptoms, such as electric pain down the nerve, and you don’t recover from these at all quickly. The second thing you could do is have some soft tissue structure compress the nerve root (a lateral or central stenosis) or a space occupying lesion (far more scary) but, again, this is rare and usually very obvious with a raft of red flags to watch out for.

So, if you visit your doctor with low-back pain sometimes with pain running across the width of your back and possibly some referred pain down you legs to above your knee or knees and you are told you have a ‘trapped nerve’, like my friend’s son, raise a quizzical eyebrow and say the following:

“Which nerve and where can it be trapped or are you just fobbing me off because I’ve spent more than my allocated 5 minutes in your office?”

Because I bet you have a posterior facet syndrome with widespread muscle guarding which is chiropractic business.

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Anterior head carriage: can chiropractic help

Monday, June 29th, 2009

What is it?

 

Seen standing upright from the side someone with perfect posture would have an imaginary centre of gravity line running from just in front of their ear hole through the slight bump on the top-middle of their shoulder.  Normally, the centre of gravity of their head is slightly forward of this line so that a very slight muscle tone is required to keep the head looking forward.  This tone may act to prevent sudden uncontrolled movements of the head, or lolling (you will have personal experienced of this if you have ever fallen asleep sitting up where your head will fall forwards and your inactive muscles suddenly crank up into action and you jerk upright again).  

         

What you get in anterior head carriage is the centre of gravity of the head moving a significant distance forward of the correct centre of gravity line.  In some cases I have seen this has been up to 6cm forward of the correct line. 

 

The problem is spectacularly and increasingly prevalent because of what we do in our lives and, I suspect, is set to get worse and worse as the Wii generation grow up.  It is easy to spot, just go and stand next to someone and look to see if their ear hole is forward of the mid-shoulder line.  I suspect you’ll be surprised how prevent it is, in fact I think if you did a statistical analysis of your friends it would be the statistical norm, but still wrong, posture.

 

How does it occur?

 

The key cause is computer use, especially laptops.  Carrying heavy bags or back packs, lazy posture and telly time with little or no exercise also don’t help but it is the eight hours a day for 30 years that really does the trick especially if it starts when you are young – say in your teens.  Computer work keeps you in a static position (usually a forward curved position as well) for long periods of time, which is why getting up and moving around every 15-20 minutes will help.

 

Backpacks also do it by increasing the overall load on the spine as well as by focusing that extra load onto the shoulders, which is where the major muscles that attach to the back of the skull originate, so putting a much larger strain onto the mechanism of anterior head carriage than the weight of the load would indicate.

 

The other place it I have seen it is in young girls who are tall and they are trying to height hide, though this is getting less common as they don’t fret about it as much as they used to. 

 

What’s the problem with it?

 

The way you achieve anterior head carriage is by straightening your cervical spine from C2 to C7 and in some extreme cases I have even seen reverse curving in the neck. 

 

In terms of skeletal problems this means that you are removing the elegant shock absorbing cervical curve and turning the neck into a column which transfers the weight of the head straight down the neck through the discs and the posterior facets leading to disc damage and facet injury.  This also places the cervical facets in an abnormal position which means they are far more likely to sustain injury.  It is rare for a patient to present at the clinic with non-traumatic acute posterior facet syndrome (you know the sort of thing – the “I don’t know what I did but I woke up like this” cricked neck complaint) who has not got significant anterior head carriage.  Also with anterior head carriage the posterior fibres of the disc annulus get stretched which increases the risk of posterior disc rupture, protrusion or bulge and the subsequent events associated with these grim conditions.

 

In neurological terms a straight cervical spine means that your spinal cord, and therefore nearly every nerve in your body, is physically straightened.  Now, nerves are designed to take this stretch as you look down but only for a short time and there are some interesting studies out there showing the changed anatomy of the spinal cord in a chronic anterior head carriage patient.  Stretched nerves have been shown to function less effectively and their axoplasmic flow is reduced.  I don’t suspect that there is a great deal of tolerance built into the human system. 

 

From the perspective of upper cervical care, when your head and neck are no longer in proper alignment to each other, your muscles have to pick up the slack of supporting your head.  This results in a higher muscle tone in your neck and upper back leading to trigger points in the Traps and Lev Scap muscles.  If you think of the force your muscles have to develop to keep your head from pivoting round your low-cervical vertebrae and smashing into your keyboard you can see why your low-cervical vertebrae suffer.  It is similar to the trick of trying to hold a plank up by the thin end – fine when it’s well balanced but once it comes away from the centre of gravity it takes masses of muscle power to keep it there – it’s all to do with levers.  No wonder people have shoulder trigger points that never seem to resolve; the underlying problem hasn’t been resolved and the outcome will remain the same.

 

The result is neck and upper back pain, restricted cervical biomechanics and all the physiological changes that would be associated with an abnormally functioning neck and upper spine. 

 

Now in some people I have seen there are no problems at all but in others there have been a raft of neck pain, headaches, upper body fatigue, sleep disorders and the rest.  And I would be willing to bet that more than a few people have been mistakenly diagnosed with migraine head ache or tension headache who, in reality, have anterior head carriage and tragic cervical biomechanics.

 

Cure

 

Prevention would be good.  Then if that fails adjust the spine to improve the biomechanics, soft tissue work to help the muscles cope and then some cervical spine stretches to combat the anterior head carriage posture adopted at work.

 

Just typing this up is making my neck hurt!

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