Chiropractic Care of the Upper Back

There are many sources of dysfunction in the upper back (thoracic spine) especially when we consider the numerous joints and the interlacing of muscles that comprise the thoracic spine and rib cage. If one muscle or joint is injured or inflamed, it can create a cascade of pain and dysfunction that can be difficult to treat.

Chiropractic treatment and upper back pain

The mid and upper back is known as the thoracic spine, it is the largest portion of the spine, consisting of 12 of the 25 spinal bones (vertebrae). In comparison the neck (cervical spine ) has 7 vertebrae while the lower back (lumbar spine) has 5 vertebrae articulate with ribs and together protect the thorax, hence the name, thoracic spine.

Upper back pain is a phenomenon that affects all age groups. Upper back pain while common receives much less attention than neck and lower back pain.

Thoracic disc herniation

Due to the limited motion in the thoracic spine, caused by the bony barrier of the ribs, Thoracic disc herniations are relatively rare. But when they do occur, they can create much pain and dysfunction.

Whenever practical and safe, conservative (nonsurgical) care, such as chiropractic, is advisable prior to the use of more invasive procedures, such as spinal injections or surgery.

The goal of the chiropractic treatment of thoracic disc herniation is to reduce pain and dysfunction while the body heals itself.

Since most disc extrusions naturally regress in a few months, chiropractors will attempt to reduce the pain and pressure caused by the disc herniation.

Some chiropractors will recommend nutritional support to reduce the pain and swelling associated with a disc herniation.

Myofascial pain syndrome

Fascia is a layer of connective tissue that contributes to the supportive structure of the spine and musculoskeletal system. The fascia invests or surrounds the muscles and allows for the smooth gliding of one muscle upon another. Investing fascia helps to prevent muscles from adhering to each other.

With injury, chronic postural stress or overuse, myofascial trigger points or myfascual adhesions may develop – all commonly referred to as myofascial pain syndrome.

Chiropractors treat myofascial pain syndromes such as myofascial trigger points or adhesions with manual myofascial therapy. This therapy normally includes the use of direct pressure upon the trigger point, or the use of active anchor and stretch myofascial release techniques.

Joint dysfunction

The thoracic spine is a marvel of joint interaction and complex motion patterns. Composed of a total of 220 separate joints, it makes up the lion’s share of the 313 total joints in the entire spine. With this many interactive articulation it is east to see that maintaining normal joint function, motion and position is important. Chiropractors treat thoracic joint dysfunction with chiropractic adjustments.

There are a variety of chiropractic adjustments techniques that can be used to adjust a dysfunctional joint:

                Most chiropractors employ manual adjusting techniques that utilize precise thrusting adjustments to help normalize joint function.

                Chiropractors can also use softer directional adjusting techniques or adjusting instruments to accommodate the needs of the patient

Thoracic outlet syndrome

Thoracic outlet syndrome is a disorder in which the nerves of the brachial plexus and blood vessels are compressed. This compression can cause great pain and altered sensations such as a “pins and needles” sensation in the hands.

Treatment of thoracic outlet syndrome can include stretching, manual trigger point therapy and myofascial anchor and stretch release techniques to the affected muscles. Chiropractors may also include adjustments and postural instruction.

Thoracic /shoulder dysfunction

The function of the shoulder and the upper back are interrelated. Studies have shown that thrusting manipulations applied to the thoracic spine and ribs have reduced should pain and dysfunction. Chiropractic adjustments to the thoracic region can be beneficial to certain types of should dysfunction.

There are many causes and treatment options for thoracic spine disorders. Chiropractors have a wide range of treatment options for treating these conditions. Chiropractors are increasingly joining collaborative spinal care teams as a drug-free option for treating spinal and musculoskeletal conditions. 

Adapted from Spine-Health.com Newsletter

What Is A Chiropractor?

A chiropractor is a health care professional focused on the diagnosis and treatment of neuro-muscular disorders, with and emphasis on treatment through manual adjustment and/or manipulation of the spine.

Most chiropractors seek to reduce pain and improve the functionality of patients as well as to educate them on how the can account for the own health exercise, ergonomics and other therapies to treat back pain.

Chiropractic is general categorized as alternative medicine or complementary medicine.

Chiropractors: fundamental beliefs and goals

Chiropractors focus on the intimate relationship between the nervous system and spine, and hold true the following beliefs

•                     Bio mechanical and structural derangement of the pine can affect the nervous system

•                     For many conditions chiropractic treatment can restore the structural integrity of the spine, reduce pressure on the sensitive neurological tissue and consequently improve the health of the individual.

 The treatment concept of chiropractic is to re-establish normal spinal mobility, which in turn alleviates the irritation to the spinal nerve and or re-establishes altered reflexes.

Conditions treated

Chiropractors use a variety of non-surgical treatments to treat patients with certain types of:

•                     lower back and leg pain “sciatica”

•                     neck pain

•                     repetitive stains

•                     headaches

•                     sports injuries

•                     arthritic pain

While primarily focusing on treating neuromusculoskeletal disorders, chiropractors are not exclusively limited to problems with the nervous system and musculoskeletal system.

When appropriate, chiropractors refer patients to medical doctors or other health practitioners for treatment of low back pain. Many chiropractors have a local referral network or work together with other spine specialist in a multidisciplinary or multi-specialty spine clinic.

Chiropractic Examination

In many regards, a chiropractic examination is very similar to standard examination procedures administered by all health care providers. With that said, how chiropractors examine the structure and function of the spine and then determine specific chiropractic care from other disciplines.

Chiropractic Exam of lower back pain

An initial chiropractic exam for back pain will typically have three parts: consultation, case history and physical examination. Laboratory analysis and x-ray examination may be performed.

Many chiropractors utilize a holistic bio-mechanical concept of treating the bipedal structure in its entirety, in an attempt to balance the structure from the feet upward.

•                     Chiropractors are typically trained in multiple methods of assessing lower back pain, including:

evaluation and management services – chiropractors are trained in examine the joints, bones, muscles and tendons of the spine, head extremities and other areas of the body with the purpose of noting any misalignment, tenderness, asymmetry, defects or other problems.

•                     Neurologic and other common physical examination procedures- chiropractors are trained to perform a variety of neurologic test (nerve root compression/tension, motor strength, coordination, deep tendon and pathological reflexes, etc) and are skilled in performing orthopedic, cardiovascular and many other common examinations.

•                     Specialized assessment- chiropractors are trained to assess range of motion, stability, muscle strength, muscle tone and other assessments with the lower back

•                     Common diagnostic studies – chiropractors are trained in use of diagnostic studies and tools such as radiography (x-rays), laboratory diagnostics and neurodiagnositics.

Chiropractic Manipulation of the Cervical Spine

Manipulation of the cervical spine or neck region is a common technique utilized by doctors of chiropractic for many patients complaining of neck, upper back and shoulder/arm pain, as well as headaches. Read more about this first line of treatment for cervical spine conditions.

Types of chiropractic manipulation

The goals of cervical adjustment include reduction of pain, improved motion and restored function. There are two general approaches for cervical spine complaints:

1.                  manipulation-often thought of as the traditional chiropractic adjustment, or a high-velocity, low-amplitude (HVLA) technique

2.                  mobilization – which is a more gentle/less forceful adjustment, or a low-velocity, low-amplitude(LVLA) technique moving the joint through a tolerable range of motion.

A combination of the various approaches varies among patients depending on the chiropractors preferred technique the patients comfort and preferences and the patients response to the treatment as well as both past experience and observations made during the course of treatment.

Adjudicative therapies may include massage therapeutic hear and /or cold application, gentle stretching and strengthening exercises and more

The cracking sound

The HVLA manipulation usually results in a release called cavitation which is created in part by gas escaping from the joint capsule when the joint is moved quickly within its passive range of motion, well within its passive range of motion, well within the tissue boundaries.

This type of chiropractic adjustment creates the typical cracking sound that is often associated with joint manipulation. It sounds similar to cracking one's knuckles.

While this cracking description of a chiropractic high velocity, low-amplitude thrust may give an impression of something that is uncomfortable, many patients find the sensation is relieving and may provide immediate relief of painful symptoms.

Gentle mobilization or adjustment?

There are several reasons a chiropractor may recommend gentle (LVLA) chiropractic techniques, such as:

1.                  Patient preference: some patients do not feel comfortable with the traditional high-velocity thrust manipulation and prefer an approach that does not involve twisting their neck or joint “popping”

2.                  Provider experience: some chiropractors may favor one technique and most chiropractors utilize several approaches and often modify and adapt several techniques to the patient’s needs and preferences.

3.                  Contraindications: some patients may not be able to tolerate the traditional chiropractic adjustment based on past experience or a prior injury or condition.

Gentle techniques

If the patient cannot relax or simply dislikes the cracking feeling or sound a gentle form of chiropractic adjustment may be utilized. Some of these methods include a slower technique performed with in the passive range of joint motion.

1.                  Cervical mobilization – the chiropractor manually moves the vertebra in the neck left to right and vice verse, alternating between the side to side motion and a figure 8 movement, applied at varying degrees of moving the head forward, backward, and to the side and in rotation. This is a smooth, non-thrust type of stretch.

2.                  Cervical manual traction- the chiropractor gently pulls on the neck, stretching the cervical spine often varying the angle between flexion (forward) and extension (backward) based on comfort and searching for the correct angle to most efficiently reduce the tightness.

3.                  Cervical “drop” techniques – the chiropractor places a hand and/or finger over the spinal segment requiring the adjustment. A medium to high velocity, low amplitude thrust, or a non-thrust gradual increasing downward pressure is applied until the drop section/ head piece of the table releases and drops a short distance. The goal is to reduce the fixation or restricted motion of the cervical vertebra assisted by the special table.

Typical cervical problems

•                     Mechanical neck pain includes pain generated from muscle, tendons, joint capsules, ligaments and /or the fascia. This type of problem is a common cause of neck pain and stiffness. Most of the time, many of these tissues are simultaneously injured and can cause pain both locally as well as at a distance away from the injury site.

•                     Cervical disc problem – tears can develop in the cervical disc and /or the inside of the disc (the nucleus) can herniate through the outer part (the annulus) and trap or pinch the nerve root as it exits the spine.

•                     Cervical nerve root irritation can frequently refer pain down the arm and into the hand. Usually affecting specific regions such as the 4^th and 5^th digits, the palm side thumb to 3^rd fingers and/ or the back of the hand on the thumb, index finger side of hand depending on which nerve root is irritated.

•                     The above are tow broad examples of types of cervical spine problems that may be treated with cervical spinal manipulation. The patient needs to receive a complete exam prior to cervical manipulation.

Starting an Exercise Ball Program

Many treatment programs for low back pain incorporate use of an exercise ball (also called a stability or fitness ball) to strengthen the core muscles in the stomach and back that support the spine. Exercise ball exercises clearly work and have been adopted in non-rehabilitation exercise programs by athletes and fitness buffs looking to cross-train and strengthen their core muscles.

This article provides several simple steps to choose, get familiar with, and benefit from using an exercise ball on a regular basis.

Choosing the right exercise ball

Physical therapist, exercise trainers, chiropractors and other professionals have constructed several guidelines to use when selecting the proper exercise ball size.

When sitting upright on an exercise ball:

1.       Feet should be flat on the floor with an even weight distribution.

2.       Knees should be level or slightly lower than the pelvis – creating an angle of 90 degrees or slightly greater at the hips and knees (thighs parallel to ground or pointing down slightly).

3.       Pelvis, shoulders and ears should be in a vertical line; the body should not be leaning in any direction as a counter balance. Bouncing up and down lightly will usually produce this alignment.

Exercise balls generally come in five different diametrical sizes to be accordingly used by people of differing body compositions.

It is important to note that height alone is not the only factor in determining ball size. Because the exercise balls are flexible and offer resistance, weight is also an important factor.

A general guideline for height correspondence to diameter of exercise ball is as follows (assuming average body weight is proportional to height):

Ball diameter	Your height
45cm	5’ and under
55cm	5’1” -5’8”
65cm	5’9” -6’2”
75cm	6’3” -6’7”
85 cm	6’8” and taller

If body weight to height or larger than the average proportion, sitting on the exercise ball will compress it down more, so try using the next larger exercise ball size in order to maintain the 90-degree rule. Another factor to keep in mind is that most exercise ball sizes have some adjustability to them. If the angles at the hips and knees are much greater than 90 degrees, some air can be released to compensate and vice versa.

Bear in mind, releasing air from the exercise ball will cause it to lose air pressure. As the ball flattens out, this will actually make it more stable, as it has a larger contact area with the resisting surface and the body. This means that stabilizing and balancing exercises will become easier and will lose some effectiveness.

Exercise balls also lose pressure because of stretching from regular usuage. Therefore, as the ball ages, it may require further inflation. On the other hand, adding excessive air to the exercise ball will increase the difficulty of balancing and stabilizing, as the contact area decreases.

Starting an exercise ball program

Just siting on an exercise ball is active and requires the core body muscles to work to hold the body upright and balance on the ball. Until sitting on the exercise ball feels comfortable, it is often a good idea to not have the ball fully inflated;a slightly deflated exercise ball is more stable.

·         Sit in the center of the ball with both fee firmly on the ground about shoulder width apart, if this is difficult, than us a wider stance.

·         The knees should be in line over the ankles

·         Shoulders should be in line over the body (not hunching forward) and the head squarely over the next (not leaning forward).

One can easily sit on the exercise ball while working at a desk or computer workstation and use it as an alternative to a tradition office chair. Others prefer to sit on it while watching television. Whatever the use, sitting on an exercise ball as some point of the day is helpful to strengthen the core muscles that support the spine.

Beginning stretches

There are several stretches that are easy to do when starting to use an exercise ball. These stretching exercises help with proprioception, of the sense of the position or parts of the body relative to the rest of the body and with balance. Each of these stretches should be done slowly 8 to 12 times.

·         Move the hips from side-to- side. While sitting on the exercise ball (as described above) and keeping the knees still, move the hips gently from side to side. Pause for a second as the end of each sideways movement to allow for a gentle stretch.

·         Move hips from front – to –back. While keeping the knees still, place hands on the knees and rotate the hips forward by tucking the buttocks first under the pelvis and then push them out behind the pelvis. All the motion should be limited to the hip area, not the knees or chest. 

Does Stress Cause Back Pain?

Could my back pain be caused by stress?

No one would disagree that having back and neck pain causes stress, but what about the other way around? Could stress be the primary cause of back pain?

How does stress cause back pain?

There are a variety of theories about the causes of stress related back pain. Importantly, the overriding tenet in all of these theories is that psychological and emotional factors cause some type of physical change resulting in the back pain.

In most theories of stress related back pain, the pain cycle continues and is exacerbated as the pain leads to the patient becoming timid and anxious about daily activities. The pain cycle is characterized by:

                The patient becomes unnecessarily limited in many functions of daily life, as well as leisure activities

                This decrease in activities is due to the patient’s fear of the pain and injury

                This fear may be made worse by admonitions from doctors (and/or family and friends) to “ take it easy” due to some structural diagnosis (which may actually have nothing to do with the back pain)

                The limitations in movement and activity lead to physical reconditioning and muscle weakening, which in turn leads to more back pain

Of course, this cycle results in more pain, more fear, and more physical de-conditioning along with other reactions such as social isolation, depression and anxiety.

The diagnosis of stress related back pain.

The diagnosis of stress related back pain is often made by a through medical history and physical exam. Patients must be cautious in trying to self diagnose stress related back pain, as there may be a serious medical condition (such as a spinal tumor or infection) causing the pain. A good medical examination can usually rule out the more serious structural causes of back pain in a great majority of patients.

For cases of stress-related back pain, the history of onset of back pain is often quite variable. The pain may start with an identifiable incident or it may start insidiously. For instance, it is not uncommon for the pain to start with an incident such as a lower back sprain or strain, only to have it continue as the result of emotional factors long after the injury has healed.

In many cases there may be MRI findings such as a “disc bulge” or “degenerative disc disease” when stress-related back pain is the actual culprit. In theses instances, the MRI findings are not clinically significant and ultimately determined not to be the cause of the pain.

The overall characteristics of stress related back pain include symptoms such as: back pain and or neck pain, diffuse muscle aches, muscle tender points, sleep disturbance and fatigue, in many stress- related back pain cases, patients complain of the pain “moving forward”

In general, symptoms of stress related back pain are similar to those of fibromyalgia. 

Treatments for stress-related back pain.

The multidisciplinary approach to treating stress related back pain includes evaluation of physical,emotional cognitive and environmental factors in all types of back pain problems and develops treatments for each aspect. Thus the multidisciplinary formulation will look at the relative contributions of the following  factors :

•                      physical including de-condition and weak muscles, nerve irritation, etc

•                      emotional including depression, anxiety, anger ,etc

•                      cognitive such as negative thoughts, pessimism, hopelessness, etc.

•                      environmental such as loss of job, financial problems, etc.

This approach then develops a treatment program based upon how much each factor is thought to be influencing the pain. A mulch-disciplinary program may include such treatments as:

•                      treating the physical factors using stretches and exercises recommended by you chiropractor

•                      treating the physical and emotional factors through appropriate medications (often including anti-depressants or muscle relaxants)

•                      treating the emotional and cognitive factors through psychological pain management techniques and biofeedback

The idea of multidisciplinary treatment of back pain has been around for at least 25 years. It has been shown to be quite successful; although, the key factor in treatment outcome is the motivation of the patient to complete a rehabilitation approach.

Preventative Chiropractic Maintenance Care

Here is a question I get weekly, if not daily in my practice… Trust me, being in practice for 26 years, I have had many great questions.

Here is the question…

“Hey Doc, why does this back pain keep coming back?” 

My typical response is: well, there are lifestyle activities that may contribute or help prevent relapses:

1.      Posture

2.      Body Mechanics

3.      Regular Exercise

4.      Nutrition and Hydration

5.      Sleep

I then remind my patients, that those lifestyle decisions are “FREE”. 

Many patients do all of those lifestyle activities very well, some not so much.  Regardless, relapses tend to continue. 

So, let’s talk about the next step - Preventative Chiropractic Maintenance Care

Chiropractic maintenance care is treatment received in order to prevent future pain or health problems, prevent a relapse, and to improve quality of life.  Maintenance care is elective, so that means that the choice is yours!! 

When it comes to receiving chiropractic care, patients can be divided into three groups. 

1.      The first group of patient’s recognizes the benefit of preventative care early on and elects to receive maintenance care after they are helped through their first episode of pain.  These patients take a proactive stance on their health.

2.      The next group of patients may decide that after experiencing three or four flare-ups of pain that they would rather not let their condition to get to that point again! They realize that they do not experience as much pain (or as many health problems) when they receive chiropractic care every 4-6 weeks (for example); regardless if they are experiencing pain at that point or not.

3.      The third group of patients never elects to receive maintenance care and typically stops care once they are feeling better.  They usually reserve going to the chiropractor only when they are in severe pain or when they are experiencing a crisis.  These patients take a reactive stance on health care.  While there is nothing wrong with this approach, it does limit the number of benefits that chiropractic care can provide.  They use chiropractic for pain relief only.  

With all this being said, it is still the patient's decision to receive maintenance care.  We cannot, nor do we desire to force anyone into receiving treatment that they do not want.  We let our patients benefit from chiropractic as long as they want.  However, our job is to educate patients on all treatment options so that they can make an informed decision about their health care.

Research shows that regular chiropractic treatment can prevent degenerative changes ("arthritis") from developing.  There are many other benefits that patients report (anecdotal evidence) from receiving chiropractic care on an occasional basis, even if they are experiencing little to no pain. They are as follows:

1.      Better sleep quality - many patients sleep longer and more soundly after an adjustment.

2.      Fewer muscle spasms and numbness - normal moving spinal joints improves muscle and nerve function.

3.      Better athletic performance- symmetrical joint movement ensures that muscles do not have to strain in order to move a joint.  Many elite athletes promoted regular chiropractic care during the peak of their career: Aaron Rodgers, Tom Brady, Michael Jordan, Tiger Woods, Jerry Rice and Joe Montana to name just a few.

4.      Fewer headaches- many report less frequent headaches and migraines and if experienced, they are usually less severe.

5.      Less need for medication- Many chiropractic patients report using less medication after starting care. (Especially pain medication!)

6.      Fewer medical doctor & hospital visits- many of our maintenance patients consider us as the primary resource to manage many common musculoskeletal ailments.  Our Schubbe Resch chiropractors treat all the joints and muscles in the body. If more care is needed, a referral can be made when necessary. 

7.      Easier to Breathe- patients often report that after an adjustment they can take a deep breath again.  Mobilizing the mid back and ribs allows for as much as a 30% increase in lung capacity. Asthmatic patients often find that they have fewer attacks and use less medication when under chiropractic care.

8.      Better circulation- Older patients or sedentary patients report feeling like they have better circulation after receiving treatment

9.      Fewer Surgeries- I wish I could document how many patients have dodged a lower back or neck surgery as a result of regular chiropractic care.  Having said that, how many surgeries have occurred due to a decision not to have regular chiropractic care.  It’s like taking vitamins; we will never know what regular positive lifestyle decisions prevent…

     Fewer Health Care Costs- Let’s face it, medical care is expensive.  Being unhealthy is expensive.  Patients are facing higher insurance costs than ever.  High deductibles and co-pays are now the norm.  Relatively speaking, ethical quality chiropractic care is very affordable.  Maintaining your health and preventing future health conditions will save you money and improve the quality of your life.

As you can see, there are many benefits of receiving chiropractic care on a maintenance schedule.  However, the decision to receive preventative maintenance is always up to the patient.  Whatever you decide, we'll respect that decision.

Insurance companies may or may not cover chiropractic maintenance care.  It depends on your insurance plan and your diagnosis.  In the event your insurance does not cover maintenance, both Schubbe Resch offices have “Day of Service Payment Plans” to help make the care affordable.

Please consider Preventative Chiropractic Maintenance Care