Are cervical adjustments safe? / Model Katie May's Story

My condolences to Katie May’s family. No matter the situation, it is never fun to hear when a life is taken away. After reading articles and now after Dr. Oz’s show, my patients had many questions about Katie May’s story and wanted to know my opinions on the whole event. My thoughts:

• History taking, physical, and neurological examinations are very important on the first visit. My goal is to get to know the person and get the full understanding on the current chief complaint and past complaints. From there, I decide if certain treatments are safe and have the confidence in helping the patient in front of me. All practitioners need to make sure that the diagnosis is accurate and the treatment is based on the diagnosis and not the other way around. Don’t treat blindly!
• Cervical adjustment can cause a stroke once in 100,000 to 2 million manipulations. I know that is a wide range but still it is very unlikely. (Ref#1)
• Prove it again! My Malpractice Premium this year is exactly $1,310.81, which is less than $110/month. If insurance companies are making a bunch of money with those rates, then it is safe to say that chiropractic treatments are safe as well. Premiums are directly proportional to the amount of risk of a lawsuit or amount of work the organization may have to engage into.
•  If there were a direct relationship between a neck adjustment and causing a stroke, adjustments/manipulations would NOT be a treatment option worldwide. Chiropractic would not be a profession and some osteopathic treatments would be prohibited as well. In fact, other health professionals are learning and wanting to perform manipulations and trying to pass laws to widen their state’s scope of practice.
•  Force = Mass x Acceleration- On average, it takes about 22.5 pounds of force for a successful adjustment (Ref#2). Just another random thought, an average defensive back (who can run a 40 yard dash in 4.56secs and weighs about 200lbs) in football can produce 1600 pounds of force (Ref#3). Subtracting force disbursement from all the gear, muscle engagement by the other player, and knowing a hit is coming or even not coming; it is still less then the force needed for chiropractic treatments.

These were my responses to my patients. My thoughts are based on anatomy and physiology and making sure everything makes sense. If you cannot explain what is going on, I believe any action should not be done. There are so many other health related deaths we can talk about in our nation but it is simply the media trying to get more exposure which also means making more money on their side. Be very reasonable and understanding with everything that you read. Hope my random thoughts put your thoughts into perspective and now see where I am coming from. Feel free to email me anytime with any other questions or concerns at drjason@activesportsandspine.com.

Respectfully,

          Dr. Jason Kim

 References

Ref#1

https://www.ncbi.nlm.nih.gov/pubmed/17330693?ordinalpos=4&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

Ref#2

http://maltezopoulos.com/articles/herzog_biomechanics_of_spinal_manipulation_2010.pdf

Ref#3

http://www.popularmechanics.com/adventure/sports/a2954/4212171/

SFMA/FRC/University of Washington Strength and Conditioning

SFMA Worksheet

Functional Range Conditioning/Kinstretch

Over the past 7 months, I had the opportunity to learn from Dr. Andreo Spina at his courses called Functional Range Conditioning (FRC) and Kinstretch. His course assistants were Dewey Nielsen, Hunter Cook, Dana Heimbecker, and Kristina Antidormi; all certified Kinstretch Instructors. The course emphasizes on true MOBILITY versus flexibility

Mobility: Ability to ACTIVELY control range of motion

Flexibility: Ability to PASSIVELY achieve an extended range of motion

In my opinion, active movements have more utility then passive movements. I value an athlete’s ability to control a standing straight leg raise more than their ability to touch their toes from a standing position when assessing hip flexion and knee extension. Coincidentally, after taking the FRC course, I have been noticing more that my patients/athletes have good passive range of motion (PROM) but their active range of motion (AROM) needs work. Long story short, the goal is to bridge the gap between AROM closer to PROM.

The larger the gap between your PROM and AROM, chances of injury are higher and the difference in degrees between PROM and AROM is where you can get hurt.

By using the FRC/Kinstretch concepts, we can improve your AROM and increase your durability. That sounds good, right?

FRC/Kinstretch concepts consist of:

• Controlled Articular Rotation (CARs)
• Progressive Angular Isometric Loading (PAILs)
• Regressive Angular Isometric Loading (RAILs)
• Progressive Angular Loading (PALs)
• Regressive Angular Loading (RALs)

The quote, "If you don't use it, you lose it", rings true in many cases and especially so with your ROM at a joint level and a multi-joint level. If you do not explore and use the full capabilities of your joints, you will lose the ranges that you do not use over time. It all depends on the physical demands an individual puts on their bodies and how a cell replaces itself when it recycles out(that's a whole another blog post). For instance, years ago I visited South Korea and saw a group of 80 year old men smoking in a perfect deep squat position but my high school athletes can’t deep squat without lifting their heels off the ground. Why is that? You and I can predicted that the smokers have practiced their deep squat their whole lives. In contrast, our society does not demand our hips and knees to flex past 90 degrees and full ankle dorsiflexion gets unused. (Interesting fact: Most weight lifting shoes have a heel lift to create more dorsiflexion during a squat)

As a takeaway, move your joints fully everyday! Dr. Spina and I recommend doing light intensity CARs or Kinstretch every morning due to lying still for 7-8 hours during the night.

FRC and Kinstretch methods are used in the following organizations:

• Onnit Academy
• Minnesota Twins
• San Diego Padres
• Chicago Cubs
• Arizona Diamondbacks
• Philadelphia Phillies
• Seattle Mariners
• Portland Trailblazers
• Texas A&M
• Manchester United Soccer Club

More Kinstretch blogs to come and Kinstretch classes in the future!

Part 2 - In-season and Off-season Shoulder Rehab

In the first baseball blog, hope you learned a little more about upkeeping your body as a pitcher. Pitching is the most dynamic movement in sports, and moving a body part 8500 degrees per second, which is when the arm can spin 24 times per second if nothing is stopping it, is pretty amazing. With that said, the cocking position in pitching is the weakest position to place your shoulder into. Something dynamic on a possible unstable foundation usually displays poor outcomes. In orthopedic testings, we perform a shoulder instability test called the Apprehension test (passively putting you into a throwing position) then afterwards confirming the Apprehension test with the Relocation test (practitioner’s hand acts like a labrum). In combination of throwing torque and positioning of the shoulder when throwing, I believe finding care during and after the season is essential to give yourself the best chance to have a longer career.

As a pitcher throws more and more over their lifetime, the anterior capsule of the shoulder becomes more laxed due to the head of the humerus shifting forward repeatedly. That is why I am an advocate of resting the shoulder after a long season to give the anterior capsule a break, spend time to improve the surrounding tissue quality, and encourage performing exercises that will stabilize the shoulder during off season. Rehabbing muscles that cross the anterior shoulder like the subscapularis, biceps, coracobrachialis, pecs, and even supraspinatus is recommended. Based on other pitchers’ experience and my own, it takes about 2-4 weeks of throwing to find “it” or the release point to throw an accurate baseball. So don’t worry about losing your mechanics and losing control. It’ll come back!

Another movement that shifts the head of the humerus forward is shoulder extension. Go ahead and stand up straight and move your elbows straight back or extend your shoulder. What happens? Yes, the head of the humerus moves forward just like externally rotating the shoulder in an abducted position. Quick couple exercises/stretches that pitchers should AVOID are: tricep dips, wide-grip squats, partner stretches that involves external shoulder rotation and extension, and regular bench presses.

If you like the joint-by-joint approach by Gray Cook like myself, the scapular region should be a more stable joint and it should still move! During a throwing motion, the scapula will upwardly rotate to to keep the ball in its socket so you can position your arm into the throwing slot (this motion will decrease throughout the season due to hypertonic lat muscles). When the arms moves, the scapula should move too right? Let’s take a look at the traditional bench press. You grab your 80lbs dumbells, lay supine on the bench, have both shoulder blades locked to the bench, then you move your arms, right? Not knowingly, you are creating dysfunction in your throwing motion by not allowing the scapula to move with the arm! Here is a good alternatives:

If I were to summarize a goal for a pitcher during the season; that would to get the MOST rest days with FULL range of motion between starts as possible. Lets take an example of a high school’s ace that starts every 5 days for 10 straight weeks and who throws about 65-80 pitches a game. After his start, he runs poles, puts some ice on his shoulder for 10 mins, lightly throws during practices, and does band work on the side. He is sore and tight for three days and expects to be throw a quality outing two days later.  If we assume the pitchers gets about two days worth of rest with full ROM between their 12 starts, that’s about 24 days of rest with full ROM for the season right?

How can we get more days rest with full ROM you may ask?

After a start, the pitchers should have their posterior chain released like the posterior capsule, rotator cuffs, rhomboids, lats via Graston/FAKTR/Active Release and then mobilize their joints that got “locked up” through the pitching process. With this rehab program, the pitcher can gain one (if not two!) more full days of rest with full ROM between starts.

Would you rather have 24 days of rest or 36 days of rest in a season?

Would your chances of getting burnt out at the end of the season decrease?

Would you be more fresh for the high school state playoffs?

Would injury rates decrease?

I’ll have you answer those questions! If you have any questions, thoughts, or concerns, please comment below or email Dr. Jason at drjason@activesportsandspine.com .

References: Eric Cressey, Dave Rak, Anatomy Train

Baseball is back! Must KNOWS to prevent injuries and tips for optimal performance for baseball players!

1) #1 reason for injury is previous injury. If you have any pain, discomfort, or limitations; go see your sports rehab provider! The goal is to stay ON the field and perform at your highest level. If you’re familiar with FMS/SFMA guidelines, zeros, function painful, and dysfunctional painful are red lights and seeing your specialist is a good idea.

2) As you throw more and more(especially as a pitcher), your body is molding you to be the best human catapult as possible. There are many components to look at as we cock back to the throwing position.

• lumbar spine and thoracic spine needs to extend well

• proper shoulder flexion

• scapular upward rotation and posterior tilt

• adequate rotator cuff strength/timing

Quick test you can do at home to see shoulder flexion limitations. If this is tough for you, pitching mechanics can be improved and overhead shoulder exercises puts you at higher risk for low back injuries.

3) If your wrist flexors are strained from previous activity, please pitch with some caution. As we hear more and more pitchers with medial elbow issues (mainly ulnar collateral ligament(UCL)/”Tommy John” ligament) due to poor movement patterns or high pitch counts, this is a easy one to detect. First, go ahead and flex your front forearm muscles and tell me where most of the meat is…...inside of your elbow right?!?! All those muscles comes into a structure called the common flexor tendon and attaches to the medial epicondyle. Those muscles are important medial elbow stabilizers which restraints from valgus stress and protects that ulnar collateral ligament. There was a study done in 1996 that a fresh cadaver’s UCL fails at about 32Nm(torque) and throwing a baseball puts about 64Nm of stress onto medial side of the elbow. So where is that additional protection coming from? Yes, your wrist flexor tendons! (Side note: your brachialis muscle come across the medial elbow too and attaches to the ulnar tuberosity which will protect the UCL as well)

I read an ESPN article two days ago and read that Cliff Lee, a $25 million pitcher, is about to throw a spring training game with a common flexor tendon strain and now a surgery date may be made in the near future! Smart move? You tell me!

4) If you’re a pitcher, maintain your body weight throughout the whole season! Since you’re a human catapult, losing weight makes your base smaller/lighter and at the same time you lose momentum going down the mound. In 2014, CC Sababthia lost 40+ lbs during the offseason and guess what happened...his ERA increased and pitched only 46 innings. Even if you lost fat and gained muscle, Meghan Trainor would say; “it’s about that bas(e)”!  Maintain your weight!

Quick baseball quiz: If Dustin Pedroia and I (both 5’6) were hitting BP together with the same bat, hitting with the same bat speed, had the same contact height, and same contact angle; who hits the ball further?

Put your answers or any questions in the comment box!

References:

Cressey Sports Performance

Biomechanics of the elbow in the throwing athlete. Oper Tech Sports Med 1996

Function Movement Screening/Selective Functional Movement Assessment 

Muscles are TIGHT for a REASON

Tight muscles are not only annoying and painful but when it stops you from your exercise program it’s the worst. Our bodies are made to move and that is one reason why exercises feel so good. Here is a quick question for you…why do muscles get tight? Let me give you a few scenarios first:

1)   You are sitting in the brutal I-5 traffic and all you see are red lights ahead of you. All of a sudden, “ boom” the driver behind you tags your bumper. Since F=MA, you are absorbing the Newtons that the texting driver hits you with. Your head goes forward then hits the headrest. Your body’s natural reaction to a threat to your head and neck is to become TIGHT.

2)   You’re an overall solid runner but you need to relearn how to fire your glute muscles. To achieve proper extension of your body and friction off the ground, your lower back and hamstrings try to do the job of your glutes. Your low back and hamstrings are TIGHT…weird.

3)   It is still early in the year and 90% of people have “losing weight” on their New Year’s Resolution including you.  You decide to get a good start by running 3 miles, doing a couple push-ups and sit-ups, then end the day with a yoga class. In about 24-72 hours, DOMS (delayed onset muscle soreness) sets in and you are TIGHT.

4)   To earn your paycheck, you sit down working in front of your computer 50 hours a week. Your keystrokes average 90 words/minute and you’re “mousing” away like crazy. After a few months, you have TIGHT pecs, subscapularis, hip flexors, and hamstrings. Can you guess why?

Protection, compensation, fatigue, and sustained positions are the reasons why muscles get TIGHT. I can give different scenarios for days but here is my point. Just because you have a TIGHT muscle, massage, Graston, Active Release Technique (ART), and foam rolling is not always the solution. Yes it does feel good afterwards, but are you doing more harm then good? Can your athletic performance be compromised and putting yourself in a higher risk situation? Are you destabilizing joints by loosening up the muscles just like clipping off steel cables off a bridge?

Scenarios #3 and #4 (fatigue and sustained positions) are mostly likely to be safe for some soft tissue work. Scenario #1 (protection) would be safe as long as there are no red flags waving back and forth like fractures or any disc suspicions.  Examples like scenario #2, ITB syndrome, and taut bilateral hip adductors (compensation) should be combined with physical therapy and corrective exercises.

If you have any questions about your TIGHT muscles, go to your trusted health practitioner. Movement is all about minimizing risk!

Finding the "WHY"

Welcome to Active Sports and Spine and Happy New Year! May this year be filled with many accomplished goals and lots of happiness!

While I was going through school and learning new techniques in seminars, I realized the importance of having solid diagnostic skills. Without the most educated diagnosis and not finding the “WHY” we are treating this patient, health practitioners are treating patients blindly.  Finding improper body movements needs a keen eye in order to provide the best care possible.

Which overhead squat do you want?

When a patient enters my clinic with a complaint, I have one main goal in mind. Find the “WHY” and reason this person is coming to see me today. In combination of asking questions, performing orthopedic tests, and watching for movement errors, I want to find out if this is a PHYSICAL vs CHEMICAL problem and/or a MOBILTY vs STABILITY problem.  Joints are designed to move in a specific way and are made to be more of a stable joint or more of a mobile joint.  Physical therapist, Gray Cook, does a great job describing the alternating joint-by-joint approach. For example, if my thoracic spine doesn’t have enough mobility during a throwing motion or an overhead squat, my body will crank more on my low back joints and/or shoulders to create the throwing and overhead squat “shape.” My motion is compromised and puts extra stress on the joints then in return creates more wear and tear onto the joints.  You MUST have proper mobility and stability to prevent overuse injuries and to keep you on the field as long as possible. I know too many minor league baseball players with high major league potential that had to stop playing due to shoulder labral tears and lumbar spinous process fractures.

Could this prevent a career-ending injury? For sure.

Could this inhibit performance? For sure.

Are these important issues to address? For sure. 

Make sure to find a health practitioner you can trust and see on a regular basis. Lets promote proper movement and reduce the risk of serious injuries while improving your performance. 

References: Gray Cook, McKenzie Institute