Snow shoveling safety tips

Here in Portland, we don’t see much snow…but when we do we are ready to shovel that white stuff out of driveways and sidewalks! Anyone who has shoveled snow before knows how good a workout it can be. When you consider that the average shovelful of snow weighs 5-10 pounds, the average driveway or walkway may hold hundreds of pounds of snow. But despite the benefits, shoveling snow can also be physically stressful; bending, lifting and twisting, combined with the exposure to freezing conditions, can take a serious toll on the body. Typically, the arms, shoulders and back get sore and may occasionally feel pain. Unfortunately, pain is a sign that an injury has already occurred or that mechanically you are doing something incorrect in shoveling the snow. In short, there is a right and a wrong way to shovel snow, and paying attention to your technique can make a big difference in how you feel the next day. Here are some quick tips on how to shovel snow smarter and avoid being injured.

* Be prepared: Spray your shovel with Teflon so the snow won’t stick to it. The more snow that stays on the shovel, the heavier it gets and the more chance for injury – and frustration.

* Do a warm up first: A tight, stiff body is asking for injury.  A few minutes of stretching can save you a lot of pain later. (And when you are shoveling, don’t forget to breathe. Holding your breath makes you tight and stiff.)

* Layer your clothing: Layered clothing will keep your muscles warm and flexible. You can shed a layer if you get too hot. Make sure you wear gloves that cover your wrists completely; if your wrists get cold, then your fingers, hands and arms will be cold too.

* Wear the right shoes: Choose shoes with plenty of cushioning in the soles to absorb the impact of walking on hard, frozen ground.

* Use the right size shovel: Your shovel should be about chest high on you, allowing you to keep your back straight when lifting. A shovel with a short staff forces you to bend more to lift the load; a too-tall shovel makes the weight heavier at the end.  Also keep one hand close to the base of the shovel to balance weight and lessen the strain on your back.

* Timing is everything: Listen to weather forecasts so you can shovel in ideal conditions. If possible, wait until the afternoon to shovel. Many spinal disc injuries occur in the morning when there is increased fluid pressure in the disc because your body has been at rest all night.

* Drink lots of water: Drinking water frequently throughout the day helps to keep muscles and the body hydrated. Be careful with hot drinks like coffee or hot chocolate. Coffee contains caffeine, which ha a dehydrating effect and adds even more stress to the body.

* Use proper posture: When you do shovel, bend your knees and keep your back straight while lifting with your legs. Push the snow straight ahead; don’t try to throw it. Walk it to the snow bank. Try to shovel forward to avoid sudden twists of the torso and reduce strain on the back. The American Chiropractic Association recommends using the “scissors stance”, in which you work with your right foot forward for a few minutes then shift ot the front foot.

* Take your time: Working too hard, too fast is an easy way to strain muscles. Take frequent breaks. Shovel for about 5 minutes at a time then rest for two minutes or so.

* See your Chiropractor: Gentle spinal manipulation will help keep your back flexible and minimize the chance for injury. If you do overdo it, your Chiropractor can help you feel better and prevent further injury.

So enjoy the snow this year, but remember that when it comes to shoveling snow, safety is absolutely paramount. Taking heed of these simple tips could mean the difference between spending your day enjoying the beauty and wonder of the new snowfall or lying in bed with a sore back, sprained ankle or other injury that could have easily been avoided. Talk to your doctor for additional information.

Douglas R. Briggs, DC, Dipl. Ac., DAAPM.

TO your health December 2009.

Cold Laser therapy offered at Elixia!

Laser Therapy for Disc Herniations

By Fred Kahn, MD, FRCS(c) and Michael Patterson, MSc

Low back pain has obvious lifestyle and financial burdens; when it is accompanied by radiation of pain and numbness in the lower extremities, it can be truly debilitating. Lumbar disc herniations account for only 4 percent of low back pain patients, but account for a high percentage of low back pain costs.

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A painful disc herniation results when a tear of the annulus fibroses allows migration of the nucleus pulposus (protrusion), resulting in nerve root irritation. Lumbar disc herniations typically occur in individuals between the ages of 30-40 years,^1-2 when the nucleus pulposus is still fluid and the annulus is weakened by strenuous activity and age. Due to this relatively young demographic, poor treatment outcomes can result in decades of suffering for these patients.

Prior to the existence of imaging studies, little was known about the healing mechanism of disc herniations. Imaging studies have confirmed what has been long suspected: Disc herniations can decrease in size and even disappear spontaneously, leading to decreased pressure on the nerve root.³

In adult discs, blood vessels are normally restricted to supplying only the outer layers of the annulus. Low oxygen tension at the center of the disc leads to an anaerobic metabolism, resulting in high concentrations of lactic acid and low pH. These deficiencies in metabolite transport limit both the density and metabolic activity of disc cells.⁴ Collagen turnover time in articular cartilage is approximately 100 years⁵ and is theorized to be even longer in the disc.⁶The result is that intervertebral discs have a limited ability to recover from metabolic or mechanical injuries such as herniations.

There have been a number of mechanisms investigated in attempts to determine how disc herniations heal. It is generally accepted that the herniated disc fragments are reabsorbed.^7-8 Histological investigations have shown the presence of granulation tissue with abundant vascularization surrounding the fibrocartilaginous fragments.⁷ Within the granulation tissue, the prevailing cell types are macrophages with fibroblasts and endothelial cells.⁸ These cell types have been demonstrated to be positively affected by laser therapy. Thestimulation of macrophages and fibroblasts could be the primary mechanism by which laser therapy heals disc herniations.⁹

Inflammatory markers such as IL-1, IL-6 and TNF-a are also present at the site of disc herniations, leading to higher prostaglandin E2 concentrations. Two studies have demonstrated that laser therapy is effective in reducing prostaglandin E2 concentrations.^10-11 Bjordal has demonstrated that inflammation is greatly reduced 75, 90, and 105 minutes after active laser therapy compared to levels prior to treatment.¹¹ The reduction in inflammation appears to be another method by which laser therapy promotes healing in disc herniations.

There is substantial published research on the effectiveness of laser therapy in treating LBP and lumbar disc herniations. The majority of these research articles discuss chronic (nonspecific) low back pain either alone^12-14 or with exercise.^15-16 These positively inclined studies seem to be absent in reviews from either the American Pain Society / American College of Physicians¹⁷ or the Cochrane Collaboration.¹⁸

The Cochrane study they refer to found that “three high quality studies (168 people) separately showed statistically significant pain relief with laser therapy in the short-term (less than three months) and intermediate term (less than 6 months) when compared with sham laser therapy.”¹⁸ Two small trials (151 people), also included in the Cochrane review, independently found that the relapse rate in the laser therapy group was significantly lower than in the control group at six-month follow-up. The conclusion was that “based on these trials, with a varying population base, laser therapy dosages and comparison groups, there is insufficient data to either support or refute the effectiveness of laser therapy for low back pain.”

The resounding statements from both of these meta-analyses were that “more studies are required” and “larger trials on specific indications are warranted.” Lacking in the conclusions were any suggestion of “how many patients and studies” are required to provide sufficient evidence. A recent study examining the effectiveness of laser therapy in treating lumbar disc herniations as measured using clinical evaluation and magnetic resonance imaging (MRI) found that “low power laser therapy is effective in the treatment of patients with acute lumbar disc herniations.”²⁰

Invariably, studies provoke questions. Some of the more common parameters for consideration are duration and extent of laser therapy treatment, joules per centimeter square of irradiation, power settings, etc. One must conclude these studies and meta-analyses, although well-intentioned, may in many instances be misguided. In our experience, almost 40 percent of all patients presenting for treatment suffer from back problems characterized by severe pain, and more than 85 percent can be treated successfully with laser therapy.²¹

The financial justification for the use of laser therapy as the first line of defense in disc herniations is overwhelming. Data collected from the SPORT trial found that the average surgical procedure cost $15,139, which rises to $27,341 when other costs such as diagnostic tests and missed work are factored in.21 The cost of conservative treatment in that same study averaged $13,108. In our experience, even the most extreme example of a herniated disc patient (receiving 40 treatments), resulted in a total treatment cost of just $3,200. When diagnostic tests and health care visits are factored into this equation, the total cost of laser therapy is closer to $5,700. This is a savings of more than $20,000 versus surgery and $7,500 over standard conservative treatment. Moreover, laser therapy is noninvasive and no adverse events have been reported in more than 3,000 publications.

In summary, this review of the current literature clearly reveals some of the shortcomings of meta-analyses and the performance of studies without standardized methodologies. We conclude that medical convention has demonstrated that the relief of symptomatic disc herniations continues to be problematic; and that both conservative and surgical solutions in the majority of cases appear to be equally ineffective. While the application of appropriate therapy requires a comprehensive understanding of the anatomy, pathology and biomechanics of the spinal column, we feel that laser therapy presents the most logical and effective therapeutic approach in managing these pervasive medical conditions.

References

1. Adams MA, Hutton WC. Prolapsed intervertebral disc. A hyperflexion injury. 1981 Volvo Award in Basic Science. Spine, 1982;7:184-191.
2. Gallagher S. Letter to the editor. Spine, 2002;27:1378-1379.
3. Teplick JG, Haskin ME. Spontaneous regression of herniated nucleus pulposus. Am J Roentgenol, 1985;145(2):371-5.
4. Urban JP, Smith S, Fairbank JC. Nutrition of the intervertebral disc.Spine, 2004;29(23):2700-9.
5. Verzijl N, DeGroot J, Thorpe SR, Bank RA, Shaw JN, Lyons TJ, Bijlsma JW, Lafeber FP, Baynes JW, TeKoppele JM. Effect of collagen turnover on the accumulation of advanced glycation end products. J Biol Chem, 2000;275(50):39027-31.
6. Adams MA, Roughley PJ. What is intervertebral disc degeneration, and what causes it? Spine, 2006;31(18):2151-61.
7. Doita M, Kanatani T, Harada T, Mizuno K. Immunohistologic study of the ruptured intervertebral disc of the lumbar spine. Spine, 1996;21(2):235-41.
8. Groenblad M, Virri J, Tolonen J, Seitsalo S, Kaeaepae E, Kankare J, Myllynen P, Karaharju EO. A controlled immunohistochemical study of inflammatory cells in disc herniation tissue. Spine, 1994;19(24):2744-51.
9. Young S, Bolton P, Dyson M, Harvey W, Diamantopoulos C.Macrophage responsiveness to light therapy. Lasers Surg Med, 1989;9(5):497-505.
10. Lim W, Lee S, Kim I, Chung M, Kim M, Lim H, Park J, Kim O, Choi H. The anti-inflammatory mechanism of 635 nm light-emitting-diode irradiation compared with existing COX inhibitors. Lasers Surg Med, 2007;39(7):614-21.
11. Bjordal JM, Lopes-Martins RA, Iversen VV. A randomised, placebo controlled trial of low level laser therapy for activated Achilles tendinitis with microdialysis measurement of peritendinous prostaglandin E2 concentrations. Br J Sports Med, 2006;40(1):76-80.
12. Toya S, Motegi M, Inomata K, Ohshiro T, Maeda T. Report on a computer randomized double blind trial to determine the effectiveness of the effectiveness of the GaAlAs (830nm) diode laser for attenuation in selected pain groups. Laser Therapy, 1994;6:143-148.
13. Soriano F, Rios R, Gallium Arsenide laser treatment of chronic low back pain: a prospective, randomized and double blind study. Laser Therapy, 1998;10:175-180.
14. Basford JR, Sheffield CG, Harmsen WS. Laser therapy: a randomized, controlled trial of the effects of low-intensity Nd:YAG laser irradiation on musculoskeletal back pain. Arch Phys Med Rehabil, 1999;80(6):647-52.
15. Gur A, Karakoc M, Cevik R, Nas K, Sarac AJ, Karakoc M. Efficacy of low power laser therapy and exercise on pain and functions in chronic low back pain. Lasers Surg Med, 2003;32(3):233-8.
16. Djavid GE, Mehrdad R, Ghasemi M, Hasan-Zadeh H, Sotoodeh-Manesh A, Pouryaghoub G. In chronic low back pain, low level laser therapy combined with exercise is more beneficial than exercise alone in the long term: a randomised trial. Aust J Physiother, 2007;53(3):155-60.
17. Chou R, Huffman LH. Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline.Ann Intern Med, 2007;147(7):492-504.
18. Yousefi-Nooraie R, Schonstein E, Heidari K, Rashidian A, Pennick V, Akbari-Kamrani M, Irani S, Shakiba B, Mortaz Hejri SA, Mortaz Hejri SO, Jonaidi A. Low level laser therapy for nonspecific low-back pain.Cochrane Database Syst Rev, 2008: CD005107.
19. Bjordal JM, Klovning A, Lopes-Martins RA, Roland PD, Joensen J, Slordal L. Overviews and systematic reviews on low back pain. Ann Intern Med, 2008;148(10):789-90.
20. Unlu Z, Tasci S, Tarhan S, Pabuscu Y, Islak S. Comparison of 3 physical therapy modalities for acute pain in lumbar disc herniationmeasured by clinical evaluation and magnetic resonance imaging. J Manipulative Physiol Ther, 2008;31(3):191-8.
21. Tosteson AN, Skinner JS, Tosteson TD, Lurie JD, Andersson GB, Berven S, Grove MR, Hanscom B, Blood EA, Weinstein JN. The cost effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over two years: evidence from the Spine Patient Outcomes Research Trial (SPORT). Spine, 2008;33(19):2108-15.
22. Kahn F. Low intensity laser therapy: The clinical approach. Proc of SPIE, 2006:6140, 61400F-1-61400F-11.

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Dr. Fred Kahn is a graduate of the University of Toronto, Faculty of Medicine, a fellow of the Royal College of Surgeons of Canada and the diplomate of the American Board of Surgery. He is the founder of Meditech International, Inc.

Dr. Michael Patterson received his undergraduate and master’s degrees in medical biophysics from the University of Western Ontario. He is the research and education manager for Meditech.