Rib Pain…in Pregnancy…

Muscle and joints are a relatively common cause of chest pain¹. Costochondritis a condition that is characterised by point tenderness over the rib and sternum join that reproduces the pain complained of combined with the same side arm movement reproducing that pain too, usually the point is at the 2nd to 5th ribs and sternum join². Not to be confused with Tietzes Syndrome which includes swelling and more likely in older persons and does not get aggravated by same side arm movement. Medical training tells one that costochondritis is a self limiting problem that will go away on its own with advice to take pain killers and do nothing, even if you are pregnant.

The arm movement and a recreation of pain can be indicative of nerve involvement that is unable to slide due to unco-ordination of intercostal musculature. Notably Obliques and Transversus Muscles, but Latissimus and Serratus Anterior can also play a part in faulty rib movement patterns. Yes underlying myofascial imbalance can give rise to costochondritis and can be brought on by the development of the bump in pregnancy. accentuating previously asymptomatic myofascial imbalance.

Treatment of costochondritis has been successful with manual therapy³. The over riding concern of continuing on with muscular imbalance is that our brain will adopt your myofascial imbalance as normal. If you don’t use it you lose it; you lose the body component you do not use from the map of the body in the brain. This map is competitive and neuroplastic meaning it is adaptable and does not have any ideal or starting reference. There is no factory reset or blueprint of ideal / perfect movement of your intercostal, latissimus or serratus muscles. Your normal is what it is.

Having a myofascial imbalance that leads on to chostochondritis during pregnancy can have knock on effects during delivery. Intercostal muscle function has been shown to be predictive of delivery experience and likely complications from the expulsion phase of birth (4).

In my opinion the best interests of any women who is pregnant with costochondritis would be to resolve the issue with manual care as soon as possible. Don’t worry your bump need not get in the way.

References:

  1. Smythe H and Fam. A (1985) Musculoskeletal Chest Wall Pain. Canadian Medical Association Journal 133(5) 379-89
  2. Proulx A and Zyrd T (2009) Costochondritis: Diagnosis and Treatment American Family Physician 80 (6) 617- 620
  3. Rabey I (2008) Costochondritis: Are the Symptoms and Signs Likely Due to Neurogenic inflammation. Two Cases that Respond to Manual Therapy Directed Toward Posterior Spinal Structures. Manual Therapy 13(1) 82
  4. Demaria, F., Porcher, R., Ismael, S. S., Amarenco, G., Fritel, X., Madelenat, P. and Benifla, J.-L. (2004), Using intercostal muscle EMG to quantify maternal expulsive efforts during vaginal delivery: A pilot study. Neurourol. Urodyn., 23: 675–678

Is a Stiff Spine really Stiff?

A recent Scientific Report published by Nature looked into perceived stiffness of the spine and actual stiffness of the spine and found that when people feel as though their back is stiff it is a lack of sensory motor integration and not directly due to stiffness in the back. The prediction system of the brain uses multi sensory information to predict the movement parameters of our body. When multiple sensory inputs are not integrating then the parameters can be confining felt as a stiffness in the back. The ability to co-ordinate the sensory information of the body in the brain can result in a stiffness perception that is independent of actual stiffness.

The integration of multiple sensory signals, is what can be confused or muddled that result in back stiffness problems. When integration occurs it means that Sensation A and Sensation B are needed simultaneously to understand the body in the brain map of the body. When Sensation A occurs out of sync with Sensation B then the back can feel stiff but not actually be stiffer.

I like this paper because it may help people to step out beyond the ageing model of back problems, the lingering injury / degeneration models and the useless ‘out of place’ and ‘symmetrical’ models.

When the sensory motor experience of our body goes out of kilter we can become better at feeling changes in force generated by muscles having the knock on effect of heightening protection mechanisms because we are not expecting that much effort to move in a comparatively small way.

Regular (Annual or biannual) checks of your back by a Chiropractor is important whether you are in a sense of stiffness, or not. A Chiropractor can help to re-integrate the sensory motor experience of your body.

Nature Scientific Report 7: 9681 (August 2017)

Abdominal Pressure

Symptoms associated with abdominal pressure dysregulation can include back pain, hip pain flank pain (kidney region), bloating, heartburn, vomiting and diarrhoea. The abdominal musculature should fire in response to lower limb movement. Notably the transverse abdominus muscle, but also the obliques, rectus abdominus and lower multifidus (back muscles) are active, ready for lower limb movement (The core). When the transverse muscle doesn’t work with the multifidi muscles then the quadratus lumborum (QL) tries to take over. The QL (a back muscle) is a notoriously overactive muscle in the experience of acute and chronic back and hip pain. The QL can also be found commonly involved in chronic recurrent lower back and or hip pain. Essentially the QL tells us that our core is not functioning well, in particular the automatic readiness of the transverse, obliques, and multifidus muscles to our normal lower limb movement is dysfunctional.

The QL is the help or aka compensation. Treatment to reduce the tightness of the QL is in fact taking away ‘the help’ the body is providing for itself and thus unhelpful in the long run. However such a strategy may be symptomatically relieving in the short term.

‘Abdominal Pressure Dysregulation’ Symptoms were published in the New York State Journal of Medicine 54:1324-1330, 1954

What can I do, I have back pain…?

The best things to do for a bad back pain episode has challenged people and medical doctors for generations. In the 1980’s bed rest and even a hospital stay was the best option in the USA. In England traction was thought to be the answer to a tight contracted back, that was to gradually stretch it out. Some people had two weeks of traction as the best medical care. Today in England the main medical approach is to provide anti inflammatories and mild over the counter pain killers, with a physiotherapy referral (within a few months). The physiotherapy approach to back pain is to provide reassurance at first. Typically an episode is bad for 3-5 days and can be felt to some degree for 4-6 weeks. People’s episodes are normally over by the time a hands on approach from the NHS is provided. The way the first back pain episode is cared for can have a knock on effect to future pain episodes. If you don’t get fixed at first it just keeps on coming back until you either get fixed or get used to having back pain episodes. 1-3% of back pains will have a sinister aspect eg a red flag such as a collapse fracture

It has been known for 15 years that anti inflammatories are enzyme inhibitors that alter the natural balance between cyclooxygenase (COX) and lipooxygenase (LOX) enzymes. Altering any natural balance creates a drive to re-balance leading to more COX enzyme increasing inflammation after 2 hours. Yes there is a decrease in inflammation in the first 30-60 minutes, then a rebound increase in inflammation begins to develop surpassing previous inflammation levels at about 2 hours after taking the NSAID (Ibuprofen). The marketing of anti inflammatories is highly suggestive having a strong impact on a lot of people.

Recommendations are now recognising that for acute low back pain the best approach is to rest for the first day, then allow yourself to move around as normally as possible, light duties and slow. Consider Chiropractic Care to help (not only this episode but also future episodes – having chiropractic care for your first episode can actually prevent the next episode form occurring).

According to advise from Harvard University medical Doctors, Chiropractic Care is a very good idea. See for yourself at http://www.health.harvard.edu/blog/heres-something-completely-different-for-low-back-pain-2017070611962

When Thought Becomes Physical

Thought has been described as neural activity in the human brain. All brain activity is not thought, just certain (brain) neuron interaction is considered individual thought. If thought is the interaction of nerves in the human brain, then when we change thinking patterns, we are also changing the way neurons interact in our central nervous system.

A particular type of thought; metaphorical thought is particularly influential over the interaction of brain neurons. When a person exclaims that their back has gone – where did it go? Normally the person’s back is exactly where it previously was, so what has changed? The metaphor of a back ‘going’ describes the human experience of having a body as seen by a human brain. An experience that relies upon the spinal communication from the body to our brain and confirmation from brain to body. The back can diminish or disappear from the map of the body in the brain. That aside… If I think my back is there then it is not, I will change the interaction of the neurons in my brain, about my back, giving the impression that my back has ‘gone’.

When I alter my metaphorical thought/ ideas/ perspectives I will change the chemicals at my nerve synapses. Chemicals are molecules and molecules are physical entities. Thus sustaining a change of chemistry in a physiological system will end up with a physical change first, in the type of molecules found at nerve synapses.

A change in molecular uptake in the brain will result in different neurons downstream becoming active. What fires together wires together. Thus we begin neuroplasticity; the changing of our brain’s ‘neural net’. A physical rewiring of the human brain over time.

In the human body it takes 4 months for people to learn new muscular co-ordination and unlearn their old pattern of muscular firing / activity. Physical change in musculature has been shown to occur in just 6 weeks from thought alone – no exercise or movement required! A change in muscle mass then must lead onto a change in muscular co-ordination, (Firing) as we continue along the same thought path.

If you enjoy the idea of facilitating a desired change in your body start with your thoughts about your body e.g. What does my body mean about me? Do I have a good body? Am I in a position of freedom in my life circumstances? Is my view of my body in anyway compatible with my relationship with food?…

Back Exercise Time

A new Cochrane review of the best exercises for people with chronic back pain has been published this year (Jan 2016). The review is a meta analysis showing that there is no one best exercise for back pain yet it is important to exercise to help yourself. The type of exercise may well come down to your preference or possibly your practitioners experience or preferences.

How long do you continue until you throw in the towel; how long is long enough to know if your current type of exercise is helping? According to the new Cochrane review exercise programmes can last up to 12 weeks.

When I think about forming a habit I see that it takes humans between 29 and 230 days to form a psychological habit. When I see that body tissues can take 3 months to co-ordinate with each other in a new movement pattern I think 12 weeks seems that is only stage one of an exercise programme. When we first kinesthetically understand a movement in our body we are looking at a 12-16 week time frame. 12 weeks cannot include strength (posture), endurance, speed or co-ordination.

The internal arts of exercise such as Tai Chi, which has been shown to help chronic back pain is said to take 1000 hours of practise to become a beginner and 10000 hours to become adept. The internal arts help you to develop an representation of your body in your imagination. We actually have several body maps in our brain e.g in the basal ganglia (brain stem), the cortex, thalamus and cerebellum. This means that our internal perspective of our body can be altered by stimuli that does not originate from the body. This perhaps is why yogis have many different representations of their body; physical body, emotional body, spiritual body etc…

An exercise programme needs to make sense, be worthwhile affordable and accessible. Starting out with fascia first chiropractic to help your body get there quicker and to educate and reassure you that pain is not something to automatically fear; you could be embarking upon a realistic plan of rehabilitation. Walking the fine line of adaptation and neuroplasticity.

Fascia as a sensory organ

The connection between the tissues of the human body bring all body components together on the inside. This connection is known as fascia. Sensory nerves (pain fibres) are densely packed into the superficial fascial layer. This superficial layer lies between the dermis and the deeper fascia. One could paraphrase that the underside of the skin and the top side of the skin are both well innervated by nerves; with the underside being more densely packed with sensory nerves (pain receptors). Whilst the outside of the skin has a greater variety of specialised nerves.

The way the superficial fascia is innervated confirms the idea of Andrew Taylor Still (Father of traditional Osteopathy) that the fascia of the body is a ‘sensory organ’. More recently Helene Langevin wrote about ‘a body wide signalling network’. How information is relayed to the brain, about the body. Udup also showed an interaction between the endocrine system and fascia in his research on hormones and yoga. The human brain, seems to me, to be calculating the movement of your body based upon sensory information from fascial tissue. Thus the condition of the fascia in your body can aid or hinder how you move (proprioception), how you feel and what hormones are being produced.

If you have an inefficient (relative to your most efficient) body you might experience delayed onset muscle soreness (DOMS). Called ‘muscle soreness’ yet it is accepted that the soreness is in fact from fascial tissue. Soreness from within your fascia can mean abnormal loading and conflicting sensory motor signals are occuring within your nervous system affecting your proprioception. Abnormal loading of fascia can lead to pain of a variety of intensities. Making identifying what you are doing to bring on the DOMS or pain difficult to pin point. Adversely loaded fascial tissue can give rise to what is traditionally thought of as ‘nerve pain’ or nerve root pain. As well as other types of pain.

Next time you are thinking you have a stubborn old injury, nerve issue, strain or sprain, perhaps you need your fascia attended to? This is why with fascia first chiropractic fascia is included along with your other body tissues as a potential source of pain and discomfort.  (Fascia information above was collected from JBMT 2015 No.19). (Picture above from ‘stroll under the skin’ by Guimberteau)

Working through it…

When you are a can do-er working through discomfort can be a part of your life. Pushing the envelope to grow toward your potential is commendable and I thoroughly recommend it. When you do work through a discomfort (or a pain) you can psychologically move to a new normal; no problem. Psychologically we have no boundaries. Physically we do; the most obvious being your skin less obvious being dysafferentation.

Due to the lack of knowledge that humans have about a human body we humans can sometimes create more problems than we solve when we push through it once. When we push through it more than once we can accumulate (learn bad habits) errors. As we move with error we abnormally load our body tissues. Abnormal loading of body tissues leads to degeneration. Normally loaded tissues last a lifetime. If you are broadening your horizons your body might just thank you now for regularly taking it to Fascia First Chiropractic. Your psychology can thank you later as you enjoy your body for years longer. This is of course my opinion but here’s a little of the why:

  • The fascia of the human body talks to the brain telling it where and how your body is.
  • The superficial fascia is densely packed with pain fibres.
  • Fascia is the reason (not muscle tissue) why you get D.O.M.S. (delayed onset muscle soreness) after exercise.
  • Fascia has more free nerve endings in it than your eyes; so the potential for pain is very high.
  • Under abnormal loading fascia can grow in on itself creating an ‘in-growth’ of highly pain sensitive tissue. Perhaps how something seems to ‘go’ without due provocation.
  • The fascia is responsible for housing nerves. The nerve sheath is innervated by the nervi nervorum and could be the cause of ‘nerve’ pain. Fascia can also mimic muscle pain….
  • Increased adrenergic signalling in the fascia leads to a vasoconstriction of blood vessels slowing up nutrient delivery to your fascia. This could worsen an immune condition, a pain syndrome or a symptom that seems to be ‘stress related’.
  • Autonomic tone can change fascial stiffness; When you are stressed your autonomic tone will change as will the stiffness of your fascia (body). This stiffness needs to be balanced not just worked out.
  • The fascia feeds information into your insula nucleus in your limbic brain about the pH, temperature and ion content of your connective tissue. Your limbic system can alter your ability to handle stress, socially interact well, and alter your sensitivity to fear and pain.
  • An immune response can also stiffen your fascia through a marker known as TGF-B1. Think of how you might stiffen up and get achy when you have a bad bout of the flu. Yes it needs balancing out afterward. An autoimmune condition is when you are stuck in a constant immune response and an allergy is an immune response to a given irritant.

Fascia First Chiropractic is more than a quick click. Fascia is behind the rate at which you are currently stiffening (ageing) over time.

Source: Tozzi P. (2015) Journal of Bodywork and Movement Therapies 19 310-326.
Stroll under the Skin  A you tube video where you can see and learn more about fascia.

How might Back Pain run in families..?

Two recent studies seem to have conjoined in my mind; one is from Zurich University Chiropractic department showing brain activity relative to lumbar spine pressure such as might happen in low back pain syndromes. The other is about training mice to ‘fear’ a smell across their generations controlling for nurture. Answering the long debate of nature versus nurture. Researchers showed that without nurture the cue for a fear response can still be passed on.

The first study carried out in Zurich; showed that back pain is linked to a part (nucleus) of the brain involved in social pain. What if we as humans could pass on in our genes information that affects the life experience of the next generation? You may find yourself as an individual with a back symptom from ‘nowhere’ due to an ancestral social cue. In generations passed going out of favour with the group could have had deadly consequences.

The second study was published in Nature Neuroscience (2014; 17, 89-96) demonstrating a transference of a fear response genetically; without nurture. The mice were shown to pass on a (protective) smell memory to their children and their grandchildren (F2).

If we as a species can have an ancestral cue for a social stress causing back pain passed on from family member to family member and social stress is not considered in your care plan. You could be forgiven for thinking that you have to ‘live’ with pain. Identifying potential cues from your environment ‘stressors’ to your behaviours, thoughts and/or feelings can be methodologically worked through. Whilst you figure out the cues to your stresses consider having body work to help you with accumulation. Accumulation in my opinion can make your condition worse.

I think when human body tissues are abnormally loaded the tissues do not undergo a training effect and instead are strained. Having a genetic fear response in social conditions where I reflexively squeeze my back muscles from an unidentified cue, providing pressure on my vertebrae, would be an abnormal load; like a repetitive strain scenario on the low back tissues of the body. Choose fascia first chiropractic it is more than a ‘quick click’.

Why wasn’t I treated at the site of my pain?

At first learning about the human body can be confusing at best, for the human body is a complex thing to attempt to understand.

In 2007 prominent physiotherapists published a paper on regional interdependence. This is a type of pain that occurs at a distant site to the root cause of pain (nociceptive). E.G that the thoracic spine can be the cause of neck pain, and a not so obvious one that the foot can stop head rotation short. Essentially almost any part of the body can affect any other part as we are well interconnected (hopefully!). The body in fact is bidirectional within itself (Tech bit: in a lower motor neurone way). The knee could cause the painful low back experience of an individual but does not give any pain at the knee. Regional Interdependent pain is different to referred pain as referred pain had been mapped and is known. In a case of interdependent pain the body worker assessing you would have to understand the link in order to help you with your problem. If the site of pain is treated then the problem can be made worse in the case of interdependent pain. Body workers such as chiropractors have ways of identifying areas to treat that are not pain based. Which is why some people have regular care; gaining benefit without the pain involved in a flare up.

Chiropractors are educated intellectually and trained in manual procedures differently to specialist manual physiotherapists, hence why in the case of a person with regional interdependent pain, we find that tacitly the concept is already part of chiropractic care plans to help musculoskeletal pain experiences. In other words: My pain does not always signify the body part that requires treatment. There will be an order of care in your chiropractic care plan that involves you finishing the course of treatment. Chiropractic is more than a quick click.