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A 45-yr old lady with mid-back pain

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A few weeks ago I did a cycle ride from Bath to Bristol. I cycled down to Didcot and took my folding bike on the train to Bath to meet up with Alex, (the older son). While I was waiting for him outside Bath station I popped into the bike shop there (it’s brilliant, btw) and bought a mini-pump, just in case we had a puncture. 

The mini-pump got me thinking about the first patient that I ever saw, while I was a student chiropractor down at the AECC college in Bournemouth in the mid 1980s. This lady was in her mid forties and had back pain, in between her shoulder blades. She was a smoker and did enjoy a glass of wine…. I thought that she had a problem with her thoracic spine, but with the benefit of hindsight, she probably didn’t. Mid-back pain is often caused by reflux of the acidic stomach contents up the oesophagus, and by stomach ulcers. The acid in the stomach is produced by parietal cells that ‘pump’ acid into the stomach to help with food digestion. This is why the mini-pump made me think of this patient!

These days there are some pretty effective medications called ‘proton-pump inhibitors’, that reduce the amount of acid in the stomach. A common one that you may have heard of is Omeprazole.  They are very safe, and they are effective in the treatment of the symptoms of acid reflux and stomach ulcers. However, like all medications, they have some downsides. Long-term use increases the risk of osteoporosis and fracture risk. They can also increase our risk of cardio-vascular events.

So what can we do, aside from taking these medications to minimise stomach acidity symptoms? Avoid anti-inflammatory medications  if you have reflux symptoms, because they may aggravate the issue. There was an article in the BMJ last year that made the following suggestions: 

  1. Avoid foods that precipitate reflux: coffee, alcohol, chocolate and fatty food.
  2. Avoid foods that irritate the stomach: citrus, carbonated drinks and spicy foods
  3. Avoid eating late, eating large portions, and avoid smoking. Lose weight

When chiropractors see patients with gastric and reflux issues we will often find tenderness in the mid-thoracic region as well as in the neck (more commonly the right side of the neck, I think). Interestingly the neck is the origin of the phrenic nerve, which both sends information to the diaphragm as well as receiving information from it . The diaphragm helps to prevent gastric reflux. It would be nice if treatment to the neck would help the phrenic nerve to control diaphragmatic function normally, resolving reflux problems, but sadly, this is not the case.

I do wonder, sometimes, whether we can improve the ability of the diaphragm to prevent reflux  by increasing our diaphragm tone through singing. I never did ask my patient back then to sing in the shower. Perhaps it would have helped her? Proton-pump inhibitor medications weren’t available back in 1985, but I think she probably would have benefitted from some lifestyle modifications!

Alex and I did make it to Bristol. It’s only about 14 miles. You ride through Staple Hill Tunnel which is slightly eerie, but dramatic. Someone was playing their trombone when we cycled through. We didn’t have any punctures, so the mini-pump didn’t get used on this trip. But it’s good to be prepared!

Muscle tear….or DVT?

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I’ve just done my first Parkrun. For those that don’t know anything about Parkrun, it is a free, community-led international event that happens somewhere near you on a Saturday morning. It is a 5kilometre run, which is timed. It felt like hard work, and I got too hot as I had kept my fleece on, which was obviously a mistake.  I’ll let you know what my time was at the end! Parkrun has turned exercise back into what it should be: done by all, easy to access and free. Here is a link to the Abingdon Parkrun

Anyway, after the run I saw one or two participants stretching their calf muscles with rather pained faces. Presumably they had simply pulled a muscle in the leg. A bit of stretching and a mix of exercise and rest, and they’ll be fine. One of the dilemmas that clinicians have is whether leg pain like this is just a pulled muscle or is a DVT, particularly if the patient has not been doing any exercise that might have injured a muscle. I saw one such patient a couple of weeks ago who had pain in his lower leg. He hadn’t done any vigorous exercise and the leg was a bit swollen. I wondered whether he had a deep venous thrombosis (DVT)?

A DVT is a clot of blood (or thrombus)  in one of the veins. The blood clot prevents blood flowing through the vein, hence the swelling. The worry about a DVT is that some of the thrombus can break off and travel through the heart and then get lodged in one of the pulmonary arteries that carry blood to the lungs, called a pulmonary embolism (PE). This is why you don’t want to massage the leg of someone who possibly has a DVT.   PE can cause shortness of breath and chest pain and is a cause of death. So we do need to know if these patients have a DVT or not. If they do then they need to be treated with an anticoagulant, quite typically apixaban (Eliquis).

The way that we can check to see if someone has a DVT is to use an ultrasound scanner to see whether the vein can be squashed. Arteries have tough walls and should not be squashable with compression. Veins have thin walls and should normally be squashable, a bit like a slightly flat bike tyre. If a vein has thrombus in it, it can’t be squashed, a bit like an overinflated tyre. You can see the arteries  in this video. They can’t be squashed. That’s normal. The veins are just above the arteries and in the video you can see that the vein in the right leg can be squashed. The vein in the left leg can’t be squashed because there is thrombus in it. This patient did have a DVT in his left leg.

The GP was very helpful and put him on apixaban and sent him to the Churchill hospital, where the DVT was confirmed. The anticoagulant will minimise the risk of him dying from a pulmonary embolism. Good result!

I hope that the Parkrunners who had calf muscle twinges all recover quickly. I came 222nd out of a field of 316 and did the run in 30mins 39secs. Not at all fast, but I enjoyed it, and will do it again. But if the weather is mild, I’ll leave my fleece off! There was a great sense of community. Maybe I’ll see you there one day?

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