Wall Centralization Exercise

On a previous post, we discussed centralization.  One exercise that can help with centralization is the Wall Centralization Exercise.  Often, patients benefit in performing this exercise under the guidance of a skilled Physical Therapist or Chiropractor familiar with the Mechanical Diagnosis and Therapy protocol (sometimes called McKenzie, named after the person who developed the protocol).

WALL CENTRALIZATION EXERCISE:

1. Lean against the wall with your shoulder against the wall (check with your doctor, PT, or chiropractor to make sure you are performing on the proper side)

2. Place your far foot firmly on the floor, and place your near foot (the side closer to the wall) over the planted foot, so that the near foot is not bearing any weight

3. Take a deep breath in

4. As you breathe out, slowly lean your hip into the wall

5. You may feel a point of stiffness in your low back- it is important to push through that stiffness

6. As you inhale, move back to the starting position

7. Take a deep breath, and then repeat

8. The goal for this exercise is to centralize the pain going down your leg, so that you will have less leg pain.  If this makes your back pain more intense- that is ok and expected.  After repeated repetitions, you should notice the back pain improve as well

  

Tips:

1. If you have leg pain, your goal is to pull that leg pain into your back.  This may intensify your low back pain- that is ok.  This called centralizing your symptoms when you pull the pain out of your legs and into your back

2. You should feel your back start to loosen after 10-20 repetitions

When to do:

1. 20 repetitions every morning

2. 10 repetitions after any time that you have been sitting for prolonged periods (car rides, airplane flights, sitting in class)

Centralization

CENTRALIZATION:

One approach to the management of radicular symptoms (sometimes called "sciatica") is called Mechanical Diagnosis and Therapy (MDT).  The goal of this program is to teach you how to prevent further exacerbations, and give you tools to use yourself so that if you have another exacerbation, you know how to treat it.

The key concept in an MDT program is the concept of CENTRALIZATION.

 This means that you want to pull symptoms out of your foot, leg, thigh, and buttock, and INTO your back.

- This process is called centralization because you are moving your symptoms toward the center of your body

- The goal is to move disk material away from your nerve root

- Sometimes when you perform this initially, it may actually make your back pain worse.  That is ok.  Eventually, in addition to pulling pain into your back, the goal is to make your back pain disappear.

- If the pain, instead of going into your back, goes AWAY from your back and into your buttock, thigh, leg or foot, that is called PERIPHERALIZATION.  That is not a good sign, and suggest that the disk material is pushing on your nerve root.

Sometimes, after your symptoms have improved, your therapist may work on additional strategies to help strengthen your core and prevent you from an exacerbation.

- These exercises are sometimes called LUMBAR STABILIZATION or CORE STRENGTHENING exercises.

- These are very helpful exercises. However, the concept of centralization is still the priority, because if your symptoms start to peripheralize, than means you may soon have an exacerbation of your symptoms.

- Please let your therapist or chiropractor know if you start having peripheralization, as that means you need to shift the focus back to centralization.

Anti-Inflammatory Diet

This diet was developed by my colleague Trasey Falcone, DO, and is helpful to bring down systemic inflammation.

Anti-Inflammatory Diet
Goal: Decrease foods that lead to inflammation and pain, and optimize intake of healthy protein, fats, and carbohydrates.

General Guidelines:
- Increase daily intake of a variety of colorful fruits (2-3 servings) and vegetables
- Eat good protein sources at every meal
- Minimize or eliminate trans fatty acids, and partially hydrogenated oils
- Minimize or eliminate high-glycemic index foods
- Try to purchase organic fruits and vegetables and free-range meats whenever possible

Proteins:
- Use organic or free-range meats when possible
- Nut butters (almond, cashew, macadamia)
- Beans and grains (soy, millet, quinoa, lentils, and other beans)

Proteins to avoid or limit:
- Avoid charring/browning proteins/meats
- Minimize large fish such as tuna and swordfish because of mercury
- Avoid farm-raised salmon because of PCBs
- coconut, canola, or olive oil for cooking

Fats:
- Sources of omega-3 fats: flax seed oil, sardines, ocean salmon, walnuts
- Dietary supplement of high EPA/DHA fish oils (purified to eliminate mercury,
- Use dry-roasted or raw nuts

Fats to avoid:
- Eliminate deep fried and breaded fried foods (french fries, chicken nuggets, etc)
- Avoid all partially hydrogenated oils and trans fats
- Decrease saturated fats (ice cream)
- Avoid highly heated fats (crispy bacon and french fries)


Carbohydrates:
- Colorful fruits (berries, pomegranate, apples, pears and citrus fruits)
- Vegetables (organic when possible)
- Cruciferous vegetables (detoxification) broccoli, cabbage, cauliflower, kale
- Fiber-rich vegetables: chard, spinach, celery, squash, zucchini, cucumber
- Onion family: Onions, leeks, chard, garlic, chives
- Consider juicing organic vegetables to improve intake of phytochemicals
- Beans (soluble fiber and protein): Kidney, black, pinto, garbanzo, etc
- Use high-fiber, high-protein breads (3-5 gms)
- Use whole grain carbohydrate sources: quinoa, millet

Carbohydrates to avoid:
- High-glycemic index foods such as cookies, cakes, scones, muffins, potatoes, sugars, white rice, enriched pastas, white breads
- Try to avoid artificial colorings and diet beverages with aspartame
- Minimize and avoid foods containing ingredients that have MSG

Other Anti-inflammatory Foods:
- Dark chocolate (in moderation)
- Red wine (optional- and in moderation)

Long Live Repetitive Eccentric Loading!

Got a call from my buddy, who injured his hamstring hurling (check out the Seattle Gaels website for some details about this awesome sport - http://seattlegaels.com/new/gaelic-sports/hurling).

With hamstring injuries, there are two subtypes- proximal (near the buttock), and more distal.

Like with all tendon injuries, I recommend early icing and compression as mainstays of management.  There are different ways to ice, but my favorite is to use a gallon-sized ziplock bag, fill it 1/3 with ice, press out the air, and fold it back on itself with the redundant plastic.  I then slip it inside a compression short, so that you have both ice and compression.

Once the acute phase has been treated, the mainstay from an exercise standpoint is repetitive eccentric loading.  Eccentric strengthening exercises are exercises where the muscle is getting longer while you contract it- think of lowering a dumbbell after doing a biceps curl.  The hamstring is a particularly hard muscle to eccentrically load, so these are some Youtube links highlighting some good choices.

http://www.youtube.com/watch?v=AS9eqB_hZqo

http://www.youtube.com/watch?v=IbmuE4clhg4

https://www.youtube.com/watch?v=XGQ7NFG0x3o

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What should you do if you don't get better?  Well, that's obvious - come see Lake Washington Sports & Spine!  

- Diagnostically, we would do a thorough examination to make sure you don't have another injury (e.g., a lumbar radiculopathy, or SI joint arthropathy)

- If needed, we could look at the hamstring under ultrasound to assess the injury (3 times higher resolution than MRI!)

-Some patients benefit from ultrasound-guided injections, which we could do in the office.  We love the use of ultrasound- it hurts less, more accurate, more likely to work, and cool to see.  We're all about the patient experience at Lake Washington Sports & Spine.

Heal up buddy!

Journal Club: The "Ouch" Trial- Outcomes of Usual Chiropractic Care

Reviewing the OUCH trial

Outcomes of Usual Chiropractic; Harm (OUCH). A randomised controlled trial. Spine 2013 June 17, Walker BF et al

http://www.ncbi.nlm.nih.gov/pubmed/23778372#

• This study was performed in 12 chiropractic clinics
• Compared 92 patients receiving normal chiropractic care to 91 patients received a sham intervention.  Sham interventions included:
•  de-tuned ultrasound
• an Activator instrument, a hand held device that delivers a low impulse, wound to lowest output and administered on the back randomly through a tongue depressor to disperse any remaining force
• a randomly placed hand on the spine while ultrasound was administered to give a “hands on” experience
• Patients were assessed for adverse events using a questionnaire
• No severe adverse events were reported
• Relative risk (i.e., comparing the risk of chiropractic care vs sham intervention) was assessed for several criteria
• adverse event occurrence
• severe adverse events
• adverse event onset
• adverse event duration
• In all cases, there was no statistically significant difference in adverse events between chiropractic care and sham intervention

Bottom line: What does this mean for our patients? 

• Chiropractic care, like all interventions, has some risk of adverse events.  However, those risks may be overstated, and at least in this study, did not occur more frequently than sham interventions
• When considering treatment options, chiropractic care is not usually being compared to doing nothing, but rather is being compared to other treatment modalities that also have risk, including other manual therapies, medications, injections, or surgery
• For perspective, the annual death toll from NSAIDs, the most common form of anti-inflammatory medication (e.g., ibuprofen), is estimated to be between 3,200 - 16,500 annually, far higher than from chiropractic care
• We believe that chiropractic care, in appropriately selected patients, is a helpful modality, and should be considered as a treatment option
• Our approach at Lake Washington Sports & Spine is to provide patients with a breadth of treatment options, inform them of risks and rewards, to help empower patients to make the right choice for them

Journal Club: A Retrospective Analysis of Vertebral Body Fractures Following Epidural Steroid Injections

The Journal of Bone and Joint Surgery, one of the leading orthopedic journals, has published this recent article on the risk of vertebral compression fractures

http://www.ncbi.nlm.nih.gov/pubmed/23780532

First, this is a well designed retrospective study.  All retrospective studies have some limitations because of some biases that can affect reporting, so that must be kept in mind.  The sample pool was a total of 6000 patients out of a database of 50,345, which is a large study.

The looked at 3000 patients who has lumbar epidural steroid injections, and compared these patients to 3000 with low back pain who did not have an epidural steroid injection.

No significant difference was found between the two groups in terms of their baseline characteristics.  However, the risk of compression fractures did increase with additional injections.

Bottom line: What does this mean for our patients?  
- Spine injections can be a helpful to manage patients with spine conditions, and we perform these injections with guidance (either fluoroscopy or ultrasound) to minimize the need for multiple injections
- One of the risks with any type of corticosteroid injection ("cortisone shots") is that it can weaken bone, including possibly causing a compression fracture
- The risk of compression fractures did increase when patients had multiple injections
- Because of this risk, the physicians as Lake Washington Sports & Spine take care to work with the patient to make sure they understand the risks associated with any decision to have an injection
- We pride ourselves on trying to minimize the total number of injectons the patient needs.  It is common for patients to be offered a "series of three" injections, in hopes that one injection may work.  That is not our general approach.  Every decision to have any an injection, including more than one injection, is treated with the respect we would want for our family members and loved ones

Lake Washington Sports & Spine physicians highlighted at American College of Sports Medicine Annual Meeting

Garrett S. Hyman, MD, MPH, and Gary P. Chimes, MD, PhD, were featured at the American College of Sports Medicine Annual Meeting in Indianapolis, in May of 2013.

The American College of Sports Medicine (www.acsm.org) is the world's largest organization promoting sports medicine, exercise research, health, and wellness.

Dr. Hyman was the Course Leader for the Diagnostic Musculoskeletal Ultrasound course, teaching other physicians in the use of Musculoskeletal Ultrasound for treatment of sports injuries.  We are proud that Dr. Hyman was recognized as a national leader in the use of this exciting modality to help better diagnose and treat patinents!

Dr. Chimes also participated in the Musculoskeletal Course as a lecturer and instructor.  Additionally, he lectured on the topics of assessment of the spine in athletes,  and served as a panelist on case presentations for athletes with spine pain.

The physicians at Lake Washington Sports & Spine strive to provide the highest level of care for Sports, Spine, and Musculoskeletal injuries, and will continue to work with leaders at the ACSM and other organizations to help train the next generation of physicians.