Brace Yourself

There’s going to be a big storm. Somebody’s going to get walloped,” said Victor Gensini, a meteorology professor at College of DuPage outside of Chicago, “It does look like it’s going to be a doozy (1).”

Millions along the east coast are expected to be affected by a large, slow moving snow storm that could drop 2 feet or more of snow!  Now, given that I have spent the last 3.5 years in Florida, my first thought while I read the words “walloped” and “doozy” was maybe I should move back to Florida, yesterday. Photo Dec 17, 4 49 51 PMMy second thought was, moving is a lot of trouble, how about I go visit one of my sisters who won’t be affected by the storm.  Lastly, with my first two thoughts having zero probability of happening, I figured okay, let’s prepare for shoveling.  One, I have to mentally prepare, considering I dread shoveling deep, heavy, wet snow.  And two, I have to physically prepare.  Most of us underestimate the physical exertion necessary for snow shoveling.

Did you know that shoveling snow results in an average of 11,500 injuries per year and nearly 100 deaths (4)?

Snow shoveling is not your average household chore.  Photo Jan 20, 9 36 36 PMIt is strenuous exercise, requiring lifting shovelfuls of snow, that can weigh up to 30 pounds,  in freezing temperatures.  On average, 400-600 calories can be burnt per hour shoveling snow.  While this is a great form of exercise and a good way to switch up monotonous routines it effects homeowners of every kind.  There are many people who stay “in shape” throughout the year, and there are many who don’t.  According to the CDC, 80% of Americans adults do not get the recommended amount of exercise per week (3).  Given this information, large snow storms are essentially drawing out thousands of “weekend warriors.”

A seventeen year study from 1990-2006, published in the January 2011 issue of the American Journal of Emergency Medicine, broke down the distribution of injuries with the most common being:

  • 55% were soft tissue injuries
  • 16% were laceration injuries
  • 7% were fractures

The most frequently injured regions included:

  • 34% low back injuries
  • 16% arm/hand injuries
  • 15% head injuries

Most frequent cause of snow shoveling related injuries:

  • 54% acute musculoskeletal exertion (sprains, strains, disc herniations, etc.)
  • 20% slip and fall
  • 15% struck by a snow shovel (I’m curious as to how this happens)
  • 7% cardiac-related injuries (most serious!)

(4)

Given this information, sitting inside until the snow melts doesn’t seem like that bad of an idea right?  As tempting as that idea can be let’s address some ways to prevent potential snow-shoveling injuries.

Cardiac Risk Tips and Prevention

In cold temperatures your blood vessel constrict, ensuring that your major organs are receiving proper blood supply.  This results in an increase in blood pressure.  Due to this, it is important to make sure that you are dressed properly when heading outside to shovel. Dressing warmly conserves body heat, preventing vessel constriction and decreasing the spike in blood pressure.  Be sure to layer up!  Also, be sure your feet, hands and head are covered.

Take 10 minutes to warm up!  As I mentioned earlier, shoveling snow is considered strenuous exercise.  You wouldn’t skip a warm-up at the gym or prior to a sporting event.  This warm-up can be as simple as jogging in place or running up and down the stairs a few times.  Stretching can be beneficial as well.  Avoid static stretching (stretching at rest; your standard stretch and hold for 30 seconds, this type of stretch is more beneficial post-exercise).  Dynamic stretching (meaning you are moving while you stretch) would be more beneficial.  For example, arm swings across your chest, arm circles, swinging your leg forward and backwards (one at a time, hold on to something to prevent falling), lunges, squats, wrist circles, etc.  The goal is to put your muscles and joints through range of motion without exceeding their limits, to properly warm up and prepare for exercise.Photo Jan 20, 9 19 00 PM

Pace yourself!  It’s not a race to see who clears their driveway first.  Taking your time and taking breaks as needed can help keep your heart rate down.  The act of snow shoveling alone is already stressful on the heart, with the static lifting in cold temperatures. There is no need to add the extra stress of speed.  Avoid the tough guy attitude thinking you’re going to go out there and be a snow plow.  Lift smaller loads!  

Know the warning signs of a cardiac event:

  • pain or pressure in the chest
  • numbness or tingling in the neck or arms
  • a cold sweat
  • nausea
  • light-headedness
  • shortness of breath

(6)

Injury Prevention

With low back injuries being the most prevalent, proper lifting technique is key!  Avoid lifting when it’s possible.  Pushing snow is better for your back.  Be sure to keep the shovel close to your body with the handle at about hip level as you push.  When you do have to lift, use a staggered stance rather than parallel, and use your knees.  As you bend from the knees, lift with your legs while keeping your back straight.  

A good rule of thumb is to toss the snow where your toes are facing, this prevents excessive twisting and rotation. Avoid the tempting action of throwing snow over your shoulder and step into the direction you are throwing (6).  Furthermore, carry snow loads to lower piles to avoid straining to heave the snow on a high pile.  Avoid tossing the snow with your arms outstretched; this, places a lot of the weight and stress on your spine.  Be sure to walk to the pile.

Alternate!  Most people have tendencies to favor their strong side.  However, if all the stress of shoveling is placed on one side of the body, muscular imbalance and decreased flexibility can occur, increasing the potential risk for injury.  Think of it as if you were in the gym lifting weights, would you only perform bicep curls with your right arm?  I don’t think so.  So switch it up…5 tosses to the right and 5 to the left.  Be sure you also alternate which leg is leading your staggered stance (2)!

Shovel Ergonomics?

Does the type of shovel make a difference?  Simply put, yes.  Let’s break it down a bit.

The weight of the shovel is something that you can assess when deciding what kind of shovel to purchase.  The lighter the better!  Try to avoid extra weight, wood and metal shovels.  Look for shovels with a fiberglass shaft.  Be sure that the length of the shovel fits you.  With the blade on the ground the handle of the shovel should come to about chest level.  The length of the shovel is important in avoiding back strain, anything shorter than chest height could result in potential injury.

Scoop shape matters!  Given that we are looking at a potential blizzard, the deep scoop shape will help clear snow faster and is better for lifting loads.  The scoops that have a slight bend are more for pushing light accumulations of snow.  To increase the life of your purchase, look for a shovel with the metal strip across the bottom of the scoop, it can prevent the plastic scoop from breaking.

Is the ergonomic shovel better?  It can be.  It significantly decreases the excessive forward flexion of the trunk while lifting, protecting your back.  However, it can put more stress on your wrists.  To prevent excessive stress on your wrists while tossing the snow, follow the instructions above, regarding walking to the pile and tossing the snow in the direction your toes are facing.  Also in cases, where the snow is sticking inside of the scoop, use some cooking spray!

(5)

Be sure to plan ahead and set goals for your shoveling endeavors this weekend!  Clear only what needs to be cleared.  The low priority areas can melt on their own.  Also, set a schedule to go out frequently rather than waiting until all the snow has fallen.  Be sure to avoid slips and falls by wearing shoes or boots that have adequate traction and use smaller, shuffling type steps.

In conclusion: warm up, shovel, cool down, and repeat.  Above all, listen to your body!

Regardless, take those sore muscles and achy joints to a chiropractor near you!

Sources:

1.Borenstein, S. (2016, January 20). East Coast, Ohio Valley brace for possible big snowstorm. Retrieved January 20, 2016, from http://news.yahoo.com/east-coast-ohio-valley-brace-possible-big-snowstorm-185932011.html?soc_src=copy

2. Gleason, M. (2009, December 29). Avoid painful snow jobs: Check out these shoveling tips. Tulsa World. Retrieved January 19, 2016, from http://web.a.ebscohost.com.proxy.palmer.edu/ehost/detail/detail?vid=82&sid=83982075-8b07-4c28-8130-e450f73c686c@sessionmgr4005&hid=4206&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ==#AN=2W62608339070&db=n5h

3. Jaslow, R. (2013, May 3). CDC: 80 percent of American adults don’t get recommended exercise. Retrieved January 20, 2016, from http://www.cbsnews.com/news/cdc-80-percent-of-american-adults-dont-get-recommended-exercise

4. New National Study Finds 11,500 Emergency Department Visits, Nearly 100 Deaths Related to Snow Shoveling Each Year. (2011, January 17). Retrieved January 20, 2016, from http://www.nationwidechildrens.org/news-room-articles/new-national-study-finds-11500-emergency-department-visits-nearly-100-deaths-related-to-snow-shoveling-each-year?contentid=86424
5. Shovels: The Scoop on the Best Bet for You. (2015). 1(80), 18-18. Retrieved January 20, 2016, from Corporate ResourceNet.

6. Wheeler, T. (2007, February 14). If you shovel, do so carefully: Heed agencies’ advice on how to avoid heart attack or back injury. Akron Beacon Journal. Retrieved January 20, 2016, from http://www.highbeam.com/doc/1G1-159300436.html?

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Trapped in a Never-ending Cycle

“Sit up straight!”  

“Put your shoulders back!”

Or my favorite, the feeling of someone’s finger jabbing you in your back until you perk up and sit up straight, no words necessary.

Most likely we have all experienced this moment at some point in our lives, as a child or teenager growing up, a mother or grandmother would pester the importance of standing or sitting up straight.  While their motive may have been to instill good posture and manners, I am going to take this a step further.

As a chiropractor, this is me telling everyone to “sit up straight, roll your shoulders back and tuck that chin!”

With today’s technology, workplace and study habits our posture is in trouble.  We all find ourselves trapped in this never-ending cycle, sitting all day staring at a device: whether it be a computer, television, smartphone, tablet or kicking it old school  with a book.  While this cycle is detrimental to posture it can also be detrimental to health and performance.

Let’s face it, sitting at a desk, head down, reading a textbook (typical study posture) has never been beneficial for posture.  I’m sure we all at some point tried to get out of studying by saying “it hurts my back.”   Unfortunately, with today’s innovations and lifestyle it goes further than “my back hurts.”  Our backs are adapting to poor posture.  With the amount of time we spend sitting on the computer, checking our cellphones, watching television, gaming, etc. our bodies are in constant “study posture,”  or now it may be referred to as “text neck,” “ipad neck,” whatever you want to call it, it shouldn’t even exist.  

Your spine naturally has two types of curves.  The cervical and lumbar spine are naturally lordotic and the thoracic and sacral spine are naturally kyphotic.  This is what creates that S-shape when you look at a spine from the side.  These slight curves are present to ensure proper distribution of mechanical stress on the body.  As I said earlier, our spines are adapting.  Loss of cervical curvature is becoming more and more prevalent in today’s society.Photo Jan 12, 11 32 56 PM

Loss of cervical curvature due to repetitive stress results in  anterior head carriage or forward head posture. This results in anterior weight-bearing of the cervical spine, “for every inch of forward head posture, it can increase the weight of the head on the spine by an additional 10 pounds,” (Kapandji, Physiology of the Joints, Volume 3) which can have many detrimental effects including:

  • Long-term muscle strain, disc herniations and pinched nerves that can result in numbness or tingling sensations down arms in to the fingers
  • Stretching of the spinal cord 5-7 cm
  • Early signs of degenerative joint disease/ arthritis
  • Decrease cervical and shoulder range of motion with reduced stability of the shoulder blades resulting in changes to upper extremity movement patterns
  • Weakened respiratory functions
  • Decreased proprioception (Your ability to sense stimuli arising within the body regarding position, motion, and equilibrium)

Okay, so these effects aren’t good, but what do the last two mean?

The musculoskeletal system and nervous system contribute to the complex function of breathing as well as your bodies ability to be aware of its presence in space.  Increased load on your cervical spine can result in decreased respiratory function, including reduction of lung volume and vital capacity, due to decreased muscle power.    To simplify, the extra strain on your neck results in weakened neck muscles, followed by a reduction in respiratory muscle strength,  as well as an increased thoracic kyphosis.  These musculoskeletal changes, consistent with upper crossed syndrome, result in decreased thorax mobility and discoordination of proper breathing mechanics. Impairing your ability to expand your thorax and take in a normal full breath as well as expel it.Photo Jan 12, 10 50 02 PM

As an athlete:

This affects you because performance is key.  Say you are a swimmer, a pitcher, maybe a runner, all of these sports require proper shoulder range of motion whether it is propelling you through the water, throwing a fast ball or improving your mile.  Not to mention proper respiration is necessary to provide optimal oxygen for aerobic events.  Furthermore, a decrease in proprioception impairs balance, this could affect a cheerleader or gymnast, as well as those who play contact sports, leaving them potentially more prone to injuries.

How can Chiropractic help?

At this point standing up straight and rolling your shoulders back is not enough, while most of us think we are standing up straight, upon analysis our head is still forward and our shoulders are still rolled forward.  A visit to a Chiropractor could result in an assessment and treatment plan that may include:

  • Postural assessment
  • Soft tissue work and stretching of the tight muscles (see image above)
  • Strengthening of the weakened muscles (see image above)
  • Chiropractic adjustments
    • Research has shown that chiropractic adjustments have been effective in increasing cervical range of motion and decreasing forward head posture, thus increasing cervical lordosis (Gong)
    • A recent journal concluded, cervical adjustments that have “previously shown to reduce neck pain and increase joint range of motion, can also help recover the posture of persons with forward head posture and improve their respiratory functions (Kim)”
  • Neuromuscular re-education for proprioception and balance
  • Kinesio taping for postural correction and proprioception
  • Rehab exercises for at home and in the office along with foam roller recommendations
    • Here are a few examples of useful corrective exercises:
  1. Chin Tucks
    • Performed sitting, standing or lying down
    • Place your hands behind your head and interlace your fingers at the base of the skull, keeping your hands firm slightly tuck your chin, pressing the skull into your hands while feeling a stretch on the back of you neck.  Imagine sliding your head backwards with the goal of getting your ears back in line with your shoulders, hold for a few seconds and release, repeat 5-10 times, 2-3 times a day.
    • Be sure you are not using your neck to generate the movement, do not allow tipping of the chin up or down (it’s a slight tuck)
    • This exercise can also be performed without the use of your hands.  Resistance provided from a wall, car headrest, or your pillow while lying in bed will also suffice, making this exercise very convenient.  There are no excuses to get out of this one!
    • You will know you are doing this exercise right if you give yourself a double chin while performing it, consider it character building…
  2. Backwards shoulder rolls
    • Performed sitting or standing
    • Roll your shoulders backwards, roll up and backwards while being sure to squeeze your shoulder blades through the motion
    • Perform 10 shoulder rolls, 2-3 times a day
  3. Shoulder blade squeeze
    • Performed sitting or standing
    • With your arms by your side, squeeze your shoulder blades together as if you were holding a tennis ball between your shoulder blades, hold and release
    • A variant of this exercise: Hold your arms out in front of your body at shoulder height, as you squeeze your shoulder blades together bend your elbows drawing your shoulders and arms back.  Hold and release
    • Perform the shoulder blade squeeze 10 times, 2-3 times a day
  4. Wall angels
    • Performed standing with your buttock and mid-back against a wall
    • Place both of your arms against the wall in a 90 degree position with your palms facing away from the wall.  While keeping your shoulders down and back, slide your arms up and down the wall.  To visualize you are are going from a W position to a Y position then back to W, repeat.  Avoid allowing your shoulders rise to your ears while performing the movement.
      Perform 10-12 times, 2-3 times a day
  5. Doorway Pec Stretch
    • Performed standing in a door way or in front of a wall.
    • With your arm bent to 90 degrees, place the forearm of one of your arms on the wall or door frame with your fingers pointing towards the ceiling
    • In a staggered stance, gently press your chest forward to stretch the involved pectoralis muscle
    • Hold for 30-60 seconds and repeat with the other arm, perform 2-3 times on both arms, 2-3 times a day
    • Be sure to listen to your body, do not stretch beyond the point of mild discomfort

 

Sources:

Dale, P. (2013, November 5). Best Exercises to Improve Posture. Retrieved January 13, 2016, from http://www.livestrong.com/article/380524-best-exercises-to-improve-posture/

Eckmann, PhD, T., & Stoddart, BScPT, D. (2015). The Power of Posture: A program to encourage optimal posture. The Journal on Active Aging. Retrieved January 12, 2016, from PubMed.

Fishman, D. (2010, April 22). Forward Head Posture Caused by Texting. Retrieved January 13, 2016, from http://dynamicchiropractic.com/mpacms/dc/article.php?id=54612

Gong, W. (2015). The effects of cervical joint manipulation, based on passive motion analysis, on cervical lordosis, forward head posture, and cervical ROM in university students with abnormal posture of the cervical spine. J Phys Ther Sci Journal of Physical Therapy Science, 27(5), 1609-1611.

Kim, S., Kim, N., & Kim, L. (2015). Effects of cervical sustained natural apophyseal glide on forward head posture and respiratory function. J Phys Ther Sci Journal of Physical Therapy Science, 27(6), 1851-1854.

Washington Redskins vs. Dallas Cowboys…What’s With the Stretcher??

With the recent head/neck injuries that were sustained this weekend by Washington Redskins players, Dashaun Phillips and Kyshoen Jarrett (a fellow Hokie!), after helmet-to-helmet hits with the Dallas Cowboys running back Darren McFadden, I’ve decided to elaborate on what a “cervical stinger” is, who is at risk, what can be done and how it can potentially be prevented.

What is a “Cervical Stinger?”

A “burner” or “stinger” occurs after an acute traumatic event, typically involving significant contact to the head and/or shoulder. This event results in either a tensile (stretching) injury or a compressive injury to the brachial plexus, or the nerve roots that form the brachial plexus. The brachial plexus is the nerve network responsible for the innervations of the upper extremity and shoulder.

Given that the nerves are either stretched or compressed, irritation occurs, producing symptoms that are described as burning/shooting/electrical pain or paresthesia (an abnormal sensation, “pins and needles”) in one upper extremity. These symptoms can be accompanied with varying degrees of numbness and weakness that may extend down the arm to the hand. Neck pain may be present as well. This injury usually lasts only for a short period of time, resolving spontaneously, and is impermanent. However, some cases may experience prolonged symptoms, reoccurrences or permanent neurological deficit. Recurrent episodes are more likely in those athletes who have cervical stenosis (narrowing of the spinal canal in the neck) or disc herniations (DynaMed).

Who is at Risk?

Cited as being one of the most common upper extremity nerve injuries seen in competitive athletes, football players are most affected. Other athletes that may incur such injury include wrestlers, hockey players and gymnasts. It is estimated that 50-65% of collegiate football players will experience a stinger during their career (DynaMed).  For example, you all may remember David Wilson (another fellow Hokie!) who left Virginia Tech for the NFL and had to retire from football at the age of 23.  If not here is an excerpt from the New York Post:

“In January of 2014 “He had a disc removed and a fusion” then “Following a prolonged rehab from the vertebrae fusion surgery, Wilson reported to training camp July 21 and was cleared for full contact. After looking quick and strong in the first week of camp, the trouble began anew for Wilson last Tuesday, when he was forced out of practice with a neck burner after running into the back of guard Eric Herman….In light of last week’s episode of symptoms, sensory and motor, Frank and I both told David he should not play football anymore. We let David know that by playing, he would be putting himself at risk for more episodes like last week or perhaps something more serious.”   (Schwartz)

Wilson is a good example in the sense that he supports the research, not only in terms of incidence in collegiate players, but also in terms of likely risk factors. A history of previous episodes and high rates of structural abnormalities in the cervical spine are reported as likely risk factors. Based on a cohort study:

“55 collegiate and professional athletes (mean age 22 years) with history of recurrent burners evaluated with cervical spine radiographs and magnetic resonance imaging (MRI) showed cervical stenosis was present in 53%. According to MRI results 93% of these injured athletes had either cervical disc disease or cervical stenosis….. Although burners may be the result of a brachial plexus stretch injury in high school and collegiate football players seen with acute symptoms, nerve root compression in the intervertebral foramina secondary to disk disease is a more common cause in collegiate and professional players who have recurrent or chronic burner syndromes. There is a high incidence of cervical canal stenosis in football players with recurrent burner syndrome. The combination of disk disease and cervical spinal canal stenosis may lead to an alteration in normal cervical spine mechanics that may make these athletes more prone to chronic burner syndromes.”  (Levitz)

According to reports Wilson had cervical stenosis, disc removal and spinal fusion all of which the American Journal of Sports Medicine can contribute to chronic burner syndromes. However, if this is seen so often in football players of all levels I am sure you are wondering what can be done to treat and or prevent such injuries?

What can be done?

For those who have already sustained the injury, while symptoms may disappear spontaneously it is important to ensure that symptoms are completely gone. Not only in general, but also while performing the sport-specific skill. Furthermore, ensure that full range of cervical and shoulder ranges of motion (ROM) are still intact. If not rehabilitation may be necessary to improve ROM and strength. Postural exercises, manipulation to the thoracic spine and soft tissue work primarily to the scalene muscles may be incorporated to reduce tension on the affected nerves (DynaMed), sounds like a visit to the local chiropractor may be necessary!

In attempts to prevent such injuries many steps can be taken, resorting back to the Redskins vs. Cowboys game, avoiding helmet-to-helmet contact can definitely prevent such injuries.   While this weekend’s game doesn’t fit the exact definition of spearing it leads me to the topic. In recent years, the NFL has attempted to prevent this sort of injury and increase player safety by making tackles in which the contact occurs at the crown of the helmet illegal. In attempts to prevent injury it is important that players do not lead with their head!   Theoretically, in attempts to tackle in a more upright position, one should be able to maintain continued eye contact with the opposition while tackling (DynaMed).

Furthermore, it is advised that athletes avoid dropping their shoulder while tackling or wrestling.   Proper fitting/modification of football shoulder pads should be ensured and improved with lifters as necessary. Lastly, identification of postural or positional faults in sport-specific techniques needs to be addressed and corrected to prevent injury (DynaMed).

Sources

DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 905473, Burners and stingers; [updated 2014 Aug 13, cited January 4, 16]; [about 7 screens]. Available from http://search.ebscohost.com.proxy.palmer.edu/login.aspx?direct=true&db=dnh&AN=905473&site=dynamed-live&scope=site. Registration and login required.

Levitz, C., Reilly, P., & Torg, J. (1997). The Pathomechanics of Chronic, Recurrent Cervical Nerve Root Neurapraxia: The Chronic Burner Syndrome. The American Journal of Sports Medicine, 25(1), 73-76. Retrieved January 5, 2016, from PubMed.

Schwartz, P. (2014, August 4). David Wilson’s career over due to neck injury. Retrieved January 5, 2016, from http://nypost.com/2014/08/04/david-wilson-shut-down-for-2014-likely-ending-his-career/