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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?

#calfmuscle, #DVT, #calfstretching, #deepvenousthrombosis, #pulmonaryembolism, #sportsinjury, #chiropractorabingdon, #parkrun, #parkrunabingdon, #chiropractic, #BCA, #BCAfamily, #POCUS

A training day in London……

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A couple of weeks ago I went up to London to attend an ultrasound workshop. It was at Canada Water, not too far from The Shard, an amazing building! The course was run by The British Medical Ultrasound Society and was about Point Of Care UltraSound (POCUS), which is where ultrasound is performed by the clinician seeing the patient, rather than by a sonographer somewhere else in the building. Although this type of course is aimed primarily at hospital doctors, and they made up most of the audience, there was a GP there, as well as me, the only chiropractor/sonographer. My use of ultrasound is POCUS, of course, because I am the clinician, as well as being the sonographer, when I use abdominal ultrasound here in the clinic to help work out what is causing a patient’s back pain.

The first presentation was about the FAST examination (Focused Assessment with Sonography for Trauma), used in A+E departments, mainly to look for free fluid (bleeding) in patients who have had trauma. Five views are taken, looking for fluid. In this example, you can see blood in the peritoneum. Interestingly, a bleed will often form sharp triangles, which helps to differentiate it from a cyst, which doesn’t. I don’t use the FAST protocol in my patient assessment, but it was a good reminder about some of the practical aspects of an abdominal ultrasound examination (which is what I do every day).

The next presentation was about abdominal aortic aneurysms (AAAs), where there is a bulge in the main artery carrying blood to the lower body. These are most common in older men who smoke, or have smoked in the past. We are looking for an increase in the internal diameter of the artery, above 3cm, as they can rupture, with fatal results. AAAs can cause back pain, so this is certainly of interest to clinicians like chiropractors.

We then had a presentation and a practical session about the use of ultrasound scanning to detect deep venous thrombus (DVT). Veins are normally easily squashed by pressure, so the aim with ultrasound scanning is to see if the vein can be squashed. If it can’t be squashed, then there may be a DVT. I haven’t done DVT scanning in the past, and it obviously takes quite a bit of practice to develop the confidence in your interpretation to use it clinically. I can see the merits of being able to do this and being able to differentiate a DVT from a muscle tear in the calf, which is often difficult to do. This area is something that I need to do more training in and get a lot more practice!

Next up was vascular access scanning, where ultrasound is used to guide the insertion of a canula into a vein for drug administration.  Not something that I will be doing clinically, but interesting to learn about, and to practice with the help of some models. I found it quite difficult, so hats off to those clinicians doing this with ease in hospital!

We then moved on to ultrasound of the lung, looking at a variety of things for which ultrasound is helpful, including pneumothorax. Normally you should see the pleura slide over each other like in this video. In this case there is shimmering of the pleura, and comet tails, so this excludes a pneumothorax . There was lots more, of course, some of it relating to the use of ultrasound in assessing the lungs of patients who have Covid-19. Not something that I am planning on doing!

The last section was echocardiology: using ultrasound to image the chambers of the heart. Although this was really interesting, it’s not something that I shall be using in practice. It’s a challenging subject not least because most of the images of the heart are from underneath, so I found working out what was what extremely difficult!

Although, like all seminars and workshops, much of what we were covering was not applicable to me, it made me think, and also made be reflect on what areas I should do more CPD in the future. I think being able to do DVT scanning proficiently is my next aim. I was pretty exhausted by the end of the day, when I had to get the underground back across London and then catch the train home, but it was worth it! Thanks to BMUS for a great training day.

#BMUS, #ultrasound, #POCUS, #FASTscan, #AAAscan, #DVT, #lungultrasound, #echocardiography

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