[Case study] Heredity and how it contributes to back problems

Mary Anderson entered my office in July of this year with hip pain.

“Not too bad,” she said, “but I don’t want it to get worse.”

Mary had never been to a chiropractor before, but she’d finally decided she needed more than someone to just tell her nothing was wrong and it should heal on its own.

The Structural Fingerprint Exam

After a detailed history, I explained to Mary, 61, the importance of doing a thorough biomechanical examination, especially for someone who is still very active with rollerblading, skiing, hiking, and other activities, and hadn’t, to date, ever had a structural exam. She not only agreed, but also was excited to see what her structural defects were, and how they played a role in her hip pain.

We begin our exam with a complete examination of the feet. We look for toe flare, Achilles torsion (seen from the posterior), pronation, supination, and measuring of the increase or decrease of the Q angle. In Mary’s case, she had bilateral supination with a reduced Q angle bilaterally.

Range of motion in both the lumbo-sacral and cervical spine was negative for restriction or pain. Cervical compression was negative. Palpation was negative in the cervical, dorsal and lumbo-sacral regions for tenderness or spasm. Trigger point tenderness was found bilaterally in the gluteus medius as well as the left piriformis muscle. Gaenslen’s was positive on the left, toe-in test was = and L-S compression was positive for tenderness throughout the lumbar spine.

X-Ray evaluation

Although Mary presented with left hip pain, our evaluation considers both the cervical and lumbo-sacral spine, as these two areas are the most influential and influenced when thinking in terms of biomechanics. We take an A-P Open Mouth, a Lateral Cervical, an A-P L-S and a Lateral L-S. When indicated, additional views are taken. However, minimal views are taken initially so additional future films can be taken for comparison.

On Mary’s X-rays, there were many unique and telling findings. First of all, on her cervical views, it was clear there was much “deferred maintenance.” Mary had an anterior gravity line on the lateral cervical view, increasing the stresses on specific muscles and joints. With the head approximately 10 percent of the body weight, it’s only logical that anterior weight distribution will increase the aggravation of the involved muscles and joints.

C4/5 and 5/6 disc spaces were substantially degenerated, typically a result of abnormal weight distribution and long-term fixation. This leads to a reduced blood flow (oxygen and nutrition) to the disc, accelerating the degenerative process. There was also a loss of the normal cervical curve. On her open mouth view , there was a rotation of C2 in relation to the centerline of the body. This can have many implications in a patient’s health and should always become part of the larger objective to work towards improved alignment.

On Mary’s lateral L-S x-ray, her gravity line and sacral base angle were both normal. The L-S gravity line should bisect the anterior third of the sacral base and the sacral base angle should be between 36°-42°. Mary had a sacral base angle of 42°. The most telling information on Mary’s X-rays was seen on her A-P L-S view. Not only was there a severe scoliosis, but long-term weight imbalances produced a degeneration of the L3/4 disc with a mal-position of the L3 vertebrae on L4.

In my experience, this type of condition accelerates with the aging process, and if not aggressively managed, can produce near debilitating results while the patient is still at a reasonably young age.

Recommendations

Mary was informed of her structural imbalances and recommendations were made. Despite the fact that her hip was the reason for coming in, my objective was much larger and, if the recommendations were followed, would greatly alter the weight distribution in the body, changing the stresses in her left hip.

My goal was to help Mary stay physically active for the rest of her life. It had nothing to do with what the insurance companies would allow.

First of all, custom orthotics were recommended. Digital impressions are done in the weight bearing position and provide accurate findings. Many doctors use orthotics only when the feet are involved, but with any lumbo-sacral imbalance, such as Mary’s, it’s critical to provide support wherever possible, and the feet are the first sight to consider.

Next, it was clear that Mary had sites of increased stress in her spine and pelvis, reducing normal mobility in these sites. This contributed to the degenerative changes. Mary’s program needed both time and care to help restore mobility and improved balance back to these joints. Our Advanced Conditioning Program provides both time (6 months) and frequency in visits (3x’s/week to begin, 40 visits total) to allow the body the needed time to adapt to an improved environment with the necessary re-education of the involved muscles and joints.

In conjunction with my care plan, we have a personal trainer in our office who meets approximately 10 times with the patient over the 6 month period to create a personally designed exercise program. This program is based on the patient’s structural needs, their exercise objectives and our objectives. The program provides the necessary work and motivation to help patients reach levels previously unattainable.

Hereditary involvement

Shortly after Mary became a patient in our office, she told me about her daughter, a marathon runner from New York City. Liz, 27, had been seeing a chiropractor for right low back pain with radiation into her right leg that was preventing her from running. Liz felt she was improving, but her mother encouraged her to get a second opinion, especially since I ran marathons and treated many runners. The next time Liz was in town she stopped in for an exam.

Although I see many parents and children and have the opportunity to review the similarities and differences, this case was amazing with the similarities found. First of all, Liz, too, had a bilateral supination of her feet. Because she had gone through several weeks of care, most of her other test findings were negative.

X-rays

Liz’s cervical x-rays showed a significant abnormality in the lordosis on the lateral view. The gravity line was anterior, a suggestion that degenerative changes could occur if improvements weren’t made. The lateral L-S view showed a greater abnormality than her mother’s lateral L-S view. Liz had a mild anterior gravity line as well as a 49° sacral base angle. This adds to the potential stress going through Liz’s low back. On the A-P L-S view, Liz showed total similarity to her mom.

There was a scoliosis, with a convexity to the left, absent of the degeneration of the L3 disc. You can only suspect that, with the additional abnormalities, such as the sacral base angle and gravity line, Liz would also go through premature degenerative changes in her low back. This is where chiropractic needs to step forward and pro-actively begin working on patients instead of waiting for significant degeneration.

Recommendations

I encouraged Liz to continue chiropractic care, regardless of her symptoms. Patients need to comprehend that structural wellness is all about management, not damage control. We also fitted Liz for custom orthotics, as her need was the same as her mother’s. These were the primary recommendations added to many other secondary suggestions.

Conclusion

A chiropractor’s success is usually dependant on the number of new patients he or she is able to get into their office. The hereditary issue should help to encourage parents and children to go through a structural exam to learn their structural defects. Hopefully, these are learned before there is suffering involved. But, even if a doctor only works with acute patients, every patient in the office is directly related to others with structural problems.

The chiropractor who develops the confidence and ability to inquire about relatives will also build a strong family practice. This is, without a doubt, a far more cost-effective way to build a practice than seeking out only the acute injury patients in each and every family in a community.

 

Tim  Maggs, DC, has been in practice nearly 40 years, and is the developer of the concerned Parents of Young Athletes (CPOYA) Network, with the goal of offering every middle and high school athlete a biomechanical exam prior to each sports season. the network, in partnership with Foot Levelers, provides training, resources, networking opportunities, and more for DCs interested in working with young athletes. Maggs can be contacted at runningdr@aol.com or through CPOYA.com.