Post Partum and Beyond:
Managing Back Pain in Women

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:   Frankp@chiro.org

By Dr. Diane Benizzi DiMarco

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The physical stress of parenting or caring for infants and young children can impart tremendous biomechanical strain. Parenting and care taking can be done by both genders but remains a female dominant task. Daily repetitive stress from tasks that require lifting the child or infant can compromises spinal integrity. Repetitive injury to the disc, zygapophyseal joints, muscles and ligaments of the spine can result from chronic lifting, twisting and torquing, and poor posture.

The post partum patient retains a higher risk for potential injury as compared to the patient who has not endured pregnancy or has not been pregnant for an extended period of time. Fertilization propels the release of estrogen, progesterone and relaxin, hormones essential to the growth and development of the embryo and fetus. These hormones that are essential to the pregnancy cause global relaxation to the ligaments and muscles in the female pregnant patient. A conglomerate of anatomical changes created by the global laxity in muscles and ligaments compromises the stability of the spine. Spinal stabilizers, such as the abdominal muscles, lose their tone and affective ability to counteract the increasing lordodic curve. The zygapophyseal joint, the pelvis and ligaments and muscles surrounding the spinal column, lose their ability to stabilize the spine. Throughout the pregnancy, instability gradually increases. As the pregnant female proceeds from the first trimester to the third, postural adaptations can be noted. Often patients develop a transient cervical curve reversal, a posterior shift of the center of gravity to the heels of the feet, a hyperlordosis, hyperextension of the knees and a hyperkyphosis. As abdominal girth increases, excessive pressure is placed on the lumbar lordosis and the zygapophyseal joints.

These patients proceed through pregnancy with some experiencing back pain and some not. All, however, experience a change in there anatomy. Once hormonal homeostasis is reached, post-partum, global hardening of ligaments and muscles occurs. Patients may at this point begin to discover back pain previously not felt. Those who are tending to infants and small children may find themselves lifting and holding a toddler or infant for extended periods of time. Chronic contraction of the ipsilateral muscle of the arm, forearm and upper thoracic region can irritate an existing condition. Post partum women that have lax tissues and hypermobile spinal segments increase susceptibility to injury. This does not exclude injury potential to non post partum patients. Those without the concern of ligament laxity are exposed to injury potential from continued and chronic use of those muscles.

During the transition of post partum, hormones begin to reset. This event is the prerequisite to re-hardening of muscles and ligaments. The sacrifice of spinal stabilization that allows for growth and development of the fetus exposes the mother-to-be to an increased probability of back injury. Adaptations in posture, during pregnancy causes a posterior shift in the center gravity. Stabilization of the spine relies more heavily on the posterior joints. Asymmetric movement and altered biomechanics caused by hypermobility in the joint may result in adhesions about the zygapophyseal joints where re-attempts to stabilize the region becomes preemptive to spinal osteoarthritis.

Discogenic injuries can cause low back pain in women of childbearing years. The increase in ligament mobility and loss of muscle tone that creates hypermobility in the spinal segment may affect the material of the disc. The annulus fibrosis is designed to resist forward translation while containing the nucleus pulposus. Such architecture can be compromised, thus interfering with axial absorption, a function of the nucleus pulposus.

New mothers who are post-partum often resume the routine of child-care without obtaining full recovery. Laxity of the ligaments and muscles remains. Often mothers are lifting car seats, baby strollers, the child and/or other siblings into their arms and carrying the infant and other children. Many times this is done with reckless abandon to proper back ergonomics. Mothers are often fatigued and hurried to get to their destination, often with self-neglect. These activities, concurrent with laxity of muscles and tissues, create a canvas for injury to the tissues around the spine.

Patients who are caregivers, such as grandparents, nannies, adoptive parents and child care workers, are a population that too retains a high risk for back injury potential. These patients perform the repetitive movements common to care taking small children. When evaluating these patients for spinal injury, it is also important to consider their age. Grandparents and older care-givers may injure muscles of the spine, irritate an existing condition of spinal arthritis, or develop a new injury to the ligaments muscles or a bursar. Patients who are younger, those in there twenties, thirties and forties may easily injure the intervertebral disc as well as the spinal joints and tissues of the spine.

Post Partum and Beyond: Managing Back Pain

There are factors that contribute to post partum back injury beyond the obvious biomechanical strain of pregnancy and caring for young children. Women with depression, a c-section, experience chronic fatigue, have compromised nutrition or sub-clinical vitamin/mineral deficiency, or who are ill may be at an increased risk of back injury.

Depression:

Post partum hormonal fluctuations can result in the clinical state of depression known as ‘post-partum depression’. Not all women experience post-partum depression. From pregnancy to pregnancy and delivery to delivery a woman’s biochemical response can differ. Postural faults can give way to identifying a potentially depressed person. Women with a downward head tilt, a flexed cervical spine and rounded shoulders may be showing signs of depression. Depressed patients tend to abandon proper lifting techniques, exposing themselves to further injury. Conversing with post-partum women can aid in identifying the possibility for depression. Inquire about her social networks, family, church involvement, friends, and organizations to which they belong and could reach out for support. Refer patients for counseling as indicated.

Depression can affect young mothers, stay at home parents, or non-parental caregivers. Adults who choose to stay at home whether they are the parent, a family member assisting in child care or are employed as a child-care worker may experiences feelings of isolation, frustration, or feelings of being overwhelmed. Young mothers, fathers, or grandparents who formerly had a career, freedom to dine out, or enjoy entertainment, otherwise find that they have demands and responsibility that may require around the clock attention. Parents, veteran or new may have a new baby who is colic, sick, disabled or requires extensive medical attention. They may also lose touch with friends, hobbies and social calendar events. This can truly have a devastating affect. As health care providers, it is important to offer a pool of information regarding where they can seek peer interaction and professional guidance. Encourage these patients to stay active in their health. Clinicians can suggest that patients seek out their hobbies as a business that can be conducted from the home or residence to suite their schedule, such as crafting, wood working or writing. Guide them to join church groups, mothers groups or township organizations that will provide a social network and peer interaction.

Depression can also be associated with issues of weight. After childbirth, a myriad of females are affected by this. Many patients who are primiparid may unexpectedly find that after the delivery much of the weight gained during pregnancy still remains. Patients who are normally lean and thin may have a difficult time accepting this condition. Reconditioning these patients and maintaining proper posture and alignment can help augment a sound and healthy weight loss program. By avoiding injury, they can maintain an exercise curriculum that will restore health and aid in weight management. Exercise can also stave off depression through endorphin release. Exercise parameters should be discussed to provide adequate guidelines in health restoration.

Patients who have had a cesarean delivery have a longer recovery period. They have had several layers of abdominal muscle and fascia and ligaments resected. Depression may ensue do to an inability to resume their regular activities due to difficulty in mobility, and increased abdominal weakness. With each pregnancy that results in a cesarean birth the muscles of the abdomen become weaker. Permission from the obstetrician should be obtained prior to implementing an abdominal strengthening program. Patients should be consistent and moderate in their exercise until full recovery and strength is resumed. Yoga and pilates are viable options for regaining core strength and muscle stretching.

Fatigue:

Lack of sleep, new demands from the infant, breast feeding on demand and tending to other children, household chores and spousal needs can be exceedingly demanding. Techniques in lifting and reconditioning may not be implemented as required. Initially the most important aspect to recovery is to regain health and acquire as much sleep as possible. For many this requires the assistance of family and friends. Advise patients to acquire as much help as possible to facilitate the sleep they require. Other sources of fatigue include anemia, illness, chronic fatigue syndrome and metabolic disorders, especially thyroid disease.

Fatigue

New mothers/caregivers usually have no time off from work; they do not have any sick time or disability. Often fatigue becomes severe with chronic sleep deprivation. Whether caring for a newborn infant, toddler or adolescent time becomes a commodity. Nutritional compromise in mothers and care-givers is common. The demands of child-rearing often time interferes with preparation of proper well balanced meals. New parents often eat sporadically many times not even sitting to eat a meal. Moms may find that they accidentally miss a meal, only to indulge in non-health foods laden with refined sugar, saturated fats and additives when overwrought with signs of hunger... These types of eating habits can cause fatigue or exacerbate an existing condition of fatigue. In addition to having an important social network that can help facilitate wholesome meals and time for the caregiver to rest it can also serve as a support for weight control. Women who are beyond childbearing or have not experienced pregnancy may too be afflicted with improper dietary habits, a hectic and demanding schedule, stress, illness or going through a life change. Each of these women can benefit from improved eating and healthier options.

Fatigue may be an outward signal of anemia, thyroid dysfunction, or illness. According to the extensive research of Dr. Broda A. Barnes, many patients suffer from a sluggish thyroid although blood tests reveal no abnormalities. [1] He professes that recording the axillary temperature can identify a thyroid problem. See his research for further information. Patients should be advised to supplement there diet with whole food multivitamins, adequate water ( protein shakes made with water or water with lemon and stevia ) and essential fatty acids vitamins and obtain as much rest as possible, whenever possible. Muscle injury and fatigue can often be aided with proper nutrition, stretching and ergonomics. Other nutritional support for fatigue includes but is not limited to: B-complex vitamin, CoQ10 supplements and iron ( with anemia, especially women who are menstruating) supplements.

Patients who present with debilitating fatigue should be referred to their primary care physician for a full blood chemistry to include a thyroid panel, ebstein barr virus, lymes disease and cancer. Co-treat the patient and request a copy of the blood chemistry report.

Pain:

During gestation, some women may experience a decline in pain perception. It has been postulate that, as hormones are released through the pregnancy they mute pain perception. As hormones levels are reestablished pot-partum, the patient may experience a return in pain perception. Patients may experience musculoskeletal pain not felt through gestation. The re-setting of hormones to a non-gravid state is the catalyst for ligaments and muscles to regain normal elasticity. According Grey’s Anatomy a manual adjustment may be indicated to prevent mal-articulations as the hardening of the ligaments occurs. Grey’s specifically indicates that this might be particularly necessary with re-hardening of the sacroiliac ligaments. An omission of manual manipulation may cause a re-positioning of the sacrum that can result in chronic low back pain. [2] The resumption of normal ligament laxity for new mother’s is often congruent with reports low back and sacral pain not felt during pregnancy.

Thoracic pain is also common in post-partum mothers as well as care-givers. The continuous need for the newborn to be held imparts adaptations throughout the spine. The most profound affect can be to the thoracic spine. Multifactoral etiologies include: engorged breast tissue, rounded shoulder posture, and ergonomic compromises seen with lifting and carrying infants and small children. Paraphernalia to accommodate these needs will be discussed in further detail later. Ergonomic faults during the feeding process, for both nursing mothers and caregivers who engage the newborn in bottle feeding, result in a round shoulder position with either a reversal of the cervical curve or extension of the occiput on atlas and flexion of the lumbar spine. These postural changes can result in thoracic and cervical pain.

Patients should be encourages to nurse or to bottle feed the infant in a seated position. She or he should support the low back by placing a step stool or thick book under the feet, place a pillow or other support under the arm supporting the child’s weight, and if bottle feeding to support the arm that is holding the bottle. Remind them to switch arms with each feeding. There are many devices available at "baby" stores that are designed to support proper ergonomics to parents and caregivers. Maintaining good and proper posture remains at the forefront of back pain abatement. Encourage patients to investigate which is right for them. Special support pillows known as ‘boppy pillows’ are available for this use, though any home decorative pillow or bed pillow will do.

Cervical pain may ensue when patients have poor posture; when phone use is congruent with holding baby/child; and when patients engage in multitasking while holding the child or infant. Phone use while carrying the child/infant encourages a shoulder to ear position. This causes excessive contraction of the trapezious muscle, the levator scapular muscle, as well as the ipsilateral muscles of the cervical spine. Patients who adorn a child on their shoulders reflexively flex the cervical spine while holding the child above their head and resting on their shoulders.

Studies by Dishman and Bulbulion support evidence of pain amelioration post adjustment. [3, 4] Such evidence strongly indicates chiropractic as a treatment approach. Patients should also be educated regarding proper posture and ergonomics. Educate patients to do moderate neck rolls, stretching the pectoralis muscles. Encourage the use of hands free phones that discourage the shoulder to ear posture, to switch the phone from the left to right ear and vise versa and to refrain or minimize carrying the child on their shoulders.


Baby Paraphernalia…good or bad?

Armed with a conglomerate of items needed to raise an infant safely, parents and caregivers become encumbered by awkward positions and bulky items to carry.

Removable infant car seats cause the caregiver to perform a repetitious lift and torque motion resulting in discogenic injury. Repetitive injury to the annulus fibrosis causes micro tears in the annulus fibers. Perpetuated, this may result in tearing of the annular fibers with bulging or herniated the pulposus. This phenomenon is most common in individuals 25 to 40 years of age. Muscles and ligaments of the spine are not immune to the insult of asymmetric repetitive motion. Sprain/strain injuries to the ligaments of the spine and the muscles as well as injury to the facet joints are common.

Removable infant car seats are designed to face the rear or back of the car. The child can either be removed from the seat or removed with the seat, while still being safely strapped within its’ confines. The mother/caregiver who chooses to remove the entire car seat with child is exposed to aberrant posture and lifting motions. Removing the infant and car seat simultaneously is common when the infant is sleeping and does not transfer well out of the seat to a crib. It is also common to remove the infant within the car seat when the infant cannot hold its’ head erect or cannot sit up in a seat provided by a shopping wagon or again, if the infant is a sleep. Patients who engage in the repetition of removing the car seat with the infant should be directed on proper postural form with removal and carrying of the car seat. Be aware that many women/caregivers carry the car seat and infant to their destination. An infant who weighs 12–15 pounds and a car seat that weighs 10–15 pounds can impart excessive biomechanical stress to the spine. Many choose to hold the seat by the handle causing a swinging action on the side that the seat is being held. Patients also tend to lean to the contralateral side of the side holding the car seat. The repetition of this attempt to counter the encumbrance of the car seat can result in wear to the spinal joints and muscle injury.

Encourage patients to hold the car seat as close to their body as possible and to lift the car seat close to the body using both knees and not her/his back. Employing the use of ‘snap-n-go’ strollers and to use shopping wagons that allow for safe placement of the infant car seat can further reduce repetitive trauma to the spine and its’ surrounding tissues.

Educate patients on the proper removal of the infant car seat. Explain that removal of the seat should be done from the back seat of the car. Unlatch the car seat and place it on the seat of the car. Remove the infant car seat after they have exited the car and are standing perpendicular to the opening of the car door. At that time they should pull the seat as close as possible to them and lift the infant car seat as straight as they can and as close to their body as feasible. This will minimize the torque that is common when attempting to quickly remove the infant seat. Mothers/caregivers normally lean over the back seat from the back car door, unlatch the seat and proceed to lift with outstretched arms, to carry the seat or place it where they intend. Continued repetition of this spinal abuse can result in spinal injuries including injury to the disc.

Baby bathtubs

Most often on initial home bathing, the infant is washed in the sink. Due to the height of the sink, this task is gentle on the posture. Advice patients to be fully prepared with soap, towels wash cloths, diapers and ointments. Instruct them to place them in an ergonomically convenient place. As wet infants are extremely slippery, some may wish to purchase a foam or rubber insert for the sink. most of which can be used in the larger bathtubs. Patients can also use a step stool to alleviate the low back pressure from standing. Advise them to place one foot on the stool while performing their task. Once the bathing is done the patient should remove the stool to avoid an accident.

A child that is too large for the sink graduates to a baby bathtub. The bathtub is normally inserted into the adult tub. Although much safer for the infant, this encourages the mothers/caregivers to be in a kneeling position over the tub, assuming a hunched position for extended periods of time and on a daily basis. The use of a ‘kneeling’ chair may aid in obtaining a more correct posture.

Removing the baby/child from the tub may compromise spinal and postural integrity with a torque and lift motion. Educate patients to remove the baby/child with a straight back while lifting the baby as close to her body as possible.

The adult caregiver, at this point, will probably be in a kneeling down position. To avoid back strain, the adult can either lay the baby/child on a padded and clean bathroom floor to diaper and dry, or the adult can lift herself with the child in her arms, using her knees. The child or infant should be held close to the body to avoid back strain. The child/infant can then be brought safely to a changing station. Using a supportive structure while obtaining an erect standing position can be accomplished by leaning on the tub or sink. This too will lessen the pressure on the low back.

Changing the infant/toddler can often result in a forward flexed thoracic spine with a flexed cervical spine. Changing tables can aid in minimizing the effects of this. Changing table are preferred and recommended in lieu of using of the crib. Diaper changes in the crib can commonly cause the attending adult to assume a forward hunched over position. This is because the crib mattress is usually set lower than that of the changing table thus requiring the adult to hunch forward to a greater degree. Changing tables are at a more convenient height so that the infant/toddler is at approximately chest height. Amenities that encourage ergonomic placement of diaper, wipes, creams, powder and diaper pail can be found at stores that cater to infant needs. The changing table should be used as long as possible, assuming its safety outweighs is potential danger, the weight of the child exceeding the tables’ load capacity, or the child falling off.

Advice patients to remain conscientious while holding the baby, nursing the infant, changing a diaper or dressing the baby/infant, all can create postural compromises that can insult the integrity of the lumbar spine while creating a repetitive rounded shoulder and cervical flexion posture.

Spinal therapy should focus on proper intersegmental mobility to these regions while incorporating ergonomics. The lumbar spine is also a concern. Reducing pressure on the lumbar lordosis can be accomplished by using a stool for one foot, thus increasing lumbar alignment and reducing low back strain. Since an infant/toddler is changed several times per day, patients are in this position numerous times. Employing back supporting activities can assist in the reduction of disc, zygapohyseal joint and muscular injury, and enhance the results of rehabilitative exercise. Employ patients to take the time to do cervical stretches such as range of motion exercises. The same is recommended for the thoracic spine. Encourage patients to retract the scapula and to stretch the pectoralis muscles.

Play Pens

Play pens offer safety to an infant when the mom needs to be ‘hands-free’. Prevention of back injuries is often compromised while placing and removing of the infant or child in the play pen. Commonly the child is placed down into the play pen while the adult is in a flexed position. This flexed or hunched position is repeated when the child is removed. Outward stretched arms create a lifting motion that compromises the upper thoracic region. Repetition can injure the upper and middle trapezious muscle, rhomboids and levator scapular muscles. Lowering one of the side bars would be ideal in ameliorating injury potential. As of 2005, no play pens or ‘pack n plays’ are available with this accommodation. The lowering of one of the side bars would cause a collapse in the play pen. Potential hazard also exists if the adult does lower the side prior to placing the child in and after re-securing the side bar with an abrupt, jerking and snapping motion. Injury to the digits and or entire hand can result if the child places his hand near the adult if the child is seeking to be removed.

High Chairs

High chairs provide a convenient and safe way to feed and entertain a baby. Unfortunately for the adult who places the child or baby into and removes the child out of the high chair, it can actually hinder proper lifting techniques. Most high chairs are designed so that the front table of chair is removable, allowing for easy access to the seat. Once the front table is removed, the adult can seat the baby and buckle her/him. This can be done with the adult perpendicular to the high chair and at close proximity. Twisting and lifting at obscure angles can be avoided. After the baby is buckled, the front table is reattached. Simple as it may be, this ritual can become long and tedious to the adult who is anxious to seat/remove the child. Compromise is often seen in haste. The adult will forfeit removing the table and opt to place the child or baby into the chair by lifting her over the table and into the seat. This procedure will usually cause the tending adult to outstretch his or her arms and lift or lower from there. Advise patients to avoid this aberrant motion and to succumb to the arduous task of removing the front table with each sitting.

Carrying the Child

How a patient carries the infant/toddler and what he/she is doing while carrying the child is important as a mechanism of injury. Patients often favor one side over the other. The dominant side may not be the side that the infant/toddler is held. It is common to find that the dominant hand is reserved for tasking. Those who are right hand dominant have a higher propensity to carry the infant/toddle on the left side. This leaves free the dominant hand free to do chores. The postural adaptations assumed while carrying the infant/toddler usually will include jutting of the non-dominant hip while maintaining a contracted arm position at approximately seventy-five degrees abduction. The arm is bent at the forearm to securely hold the infant/toddler. This creates a repetitive strain on the muscle of the upper thoracic spine.

Carrying the infant/toddler is commonly done while multitasking. The mother/caregiver may habitually carry the child on same arm and hip so that she or he can perform other necessary tasks. Women/caregivers who need to tend to household chores such as cooking, vacuuming and dusting may attempt these activities while holding the infant/toddler. Talking on a cordless telephone, while carrying a child is a common activity. Cervical ipsilateral lateral flexion to the ipsilateral shoulder with the shoulder lifted upward allows for holding of the telephone free of hands. Cervical compromise can be observed. During a focused patient history, it is important to inquire about the activities of daily living. Ask your patient if he/she uses a hands-free phone, or if he/she talks on a wireless. The use of wireless phones encourages longer conversation. Without the restriction of the wire, patients are free to move about and accomplish tasks around the house. They are also prone to engaging in conversation while changing the baby, feeding the baby (either via nursing, a bottle or even at the high-chair), even while just holding the child. In addition to performing a focused history, be aware, a focused history can turn into an educational consult. It is here where you can advise your patients of viable alternatives, ergonomics, stretching and the importance of spinal adjustments as a way to maintain joint mobility and spinal integrity. Be sure to check for leg length inequality, a posterior or rotated sacrum, hypertonic erector spinae muscles and myofascial trigger points in the quadratus lumborum muscles, myofascial trigger points and/or hypertonic rhomboids, traps, levator scapulae, cervical muscles and sub-occipital muscle. Palpate for segmental dysfunction in each region as well as myofascial trigger points and hypertonic taught bands.

Carrying Options

Myriad carrying options exist for care givers. Front carriers, back carriers, and side carriers are now available in various sizes and designs. Although they seem like a viable option with symmetrical weight distribution, tremendous stress can be imparted on the musculoskeletal system. Front and rear carriers can compress the shoulders bilaterally causing a constant depression. Side carriers compress the shoulder it rests on in the same manner the front or rear carriers do. Patients may try to compensate for this by lifting the shoulder upward. Contraction of the ipsilateral trapezious muscle, levator scapulae muscle can cause sprain/ strain to the tissues. To accommodate the extra weight to the anterior or on the dorsum, weight distribution and the center of gravity shifts. Patients will shift their center of gravity to the anterior for rear carrying child supports or to the posterior for forward carrying child supports. Front carriers can cause patients to insinuate a posterior shift, mimicking that of pregnancy. Chronic shortening of the lumbar muscles with an increase in the lumbar lordosis may cause a facet syndrome with possible myospasm or myofascitis of the surrounding soft tissue. Carriers designed for the dorsum encourage patients to adopt a forward, anterior lean with thoracic flexion, bilateral anterior rounding of the shoulders and a compensatory cervical extension or possibly a cervical forward head carriage.

Carriers with side carrying options offer a viable option to holding an infant. This method of supporting an infant requires the use of a ‘sash’ type of carrier that swaddles the baby in a cradling fashion. It wraps across the chest and abdomen of the adult and to the posterior across the back. Downward pressure is exerted on the ipsilateral shoulder that the sash is resting.

Individuals should be encourage to research the most ergonomic and comfortable form of support for them. Instruct patients to avoid spinal compromise and opt for the carrier that maximizes spinal integrity, distributes weight evenly and incorporates the hips for additional support and balance.

A focused health history of mothers/caregivers should include inquiry regarding the use of carrying devices. You may also suggest the patient bring the support carriers in to the next visit to examine postural adaptations and possible faults.

Proper Ergonomics with Stroller Use

Purchasing a stroller can be overwhelming to new parents. Bombarded with amenities it seems that even a college degree may not be sufficient. Assisting patients in choosing a stroller may alleviate some anxiety along with saving themselves from back pain and money spent. Child safety is at the forefront when purchasing any piece of equipment intended to aid child rearing. Ergonomic consideration for the adult should be receiving as much attention. Strollers are often designed that when the adult pushes the stroller a hunched position is acquired. Advise patients to look for a stroller with handles that are high enough to avoid hunching. They should make sure that the wheels move easily and turn with little effort. All of this will abate the need to hunch and push the stroller with excess pressure on the back. Other amenities such as cup holders and pouches are important to carry bags. This will free up the hands and arms.


Exercise and Weight Control

Exercise for women post-partum or otherwise is an excellent way to attain cardiovascular health, control diabetes, decrease symptoms of menstruation and menopause, and obtain overall health. Weight gain for women is a common battle. Post pregnancy weight and weight gain from menopause can be controlled and reduced with an exercise program and healthy food choices. Women who are menopausal, pre menopausal and post menopausal are encouraged to include weight bearing exercises to combat bone resorption. Proper exercise can reduce fatigue while boosting metabolic rate, self esteem and mood.

Recreational physical fitness that becomes obsessive can be deleterious to a women's health. Female athletic activities such as running, swimming, and varied aerobics help facilitate the goal of weight loss and muscle tone. The caveat is when women calorie restricts and exercises to excess.

Body Composition of Women Concerning Exercise Parameters

The female anatomy is structurally smaller than that of men. Women average approximately 10–20% shorter while retaining a 20–25% body fat with less lean muscle than men. This compares to the male gender whose average is approximately 15% body fat. [5–7, 10–13] Structurally, the wider pelvis, larger quadriceps angle and foot pronation can cause some of the most common musculoskeletal injury patterns seen in women.

Injuries to the anterior cruciate ligament, patellofemoral injuries, foot problems, iliotibial band friction syndrome, stress fractures, and shoulder injuries are common to female exercise enthusiasts.

Female Physiology and its Relation to Exercise for Women

A woman’s physique and physiology differs from that of her male counterpart. Females experience a growth spurt earlier than boys do, which is complete approximately one to three years after menses, with cessation of linear growth approximately two years after menarche. [9, 11] Prior to puberty, female physiology, strength and body mass composition mirrors that of her male counter-part. [7–9, 11, 14] Whereas post puberty renders a significant disparity in physical ability, physiology and nutritional demands not seen in men as compared to women. Peak bone density in women is thought to have been reached by age 35 years which is less than the bone density seen in men of the same race, gender and level of physical conditioning. Fiesler attributes these disparities to the affects of androgen hormones released in the male gender and estrogens released in females. [14]

Once puberty is reached, cardiopulmonary function and oxygen-carrying capacity diverges from that in post puberty males. The hematopoietic system differs whereby the total red cells in a female are approximately 6% less than in men and hemoglobin and hematocrit concentration average 10–15 % less than normal levels. [5, 8, 9, 14] This lowers oxygen carrying capacity and may hinder exercise performance. The smaller cardiac muscle, congruent with female anatomy, reduces stroke volume. Women attempting to attain the same workload must achieve a heart rate greater than that required by a man. Women also have a comparably smaller sized thorax, which decreases vital capacity. All factors considered, a female at the same weight and level of conditioning as a male counterpart has a lower baseline maximal oxygen uptake ( VO2 max)." [5, 6, 8, 9, 14]

Female Anatomy Relative to Exercise and Injury Potential

Anatomically unique musculoskeletal characteristics of women can affect performance potential and increase the risk of injury. Physically women tend to be shorter in stature, have shorter limbs with wider torsos, and have a forearm that is longer than her arm. Women have a smaller bone structure, narrower shoulder width, less bone density, and have a wider pelvis. Pelvic variance is the most widely accepted contributing factors responsible for inhibiting athletic performance in women. Measurements of the male and female pelvis differ in more than width. Netter specifically notes that all measurements of the male pelvis are slightly shorter in relation to the body size than that of the female. He also notes that the pelvic inlet is more transverse oval in orientation whereas the male pelvic inlet is anterior to posterior in nature. The pubic symphasis in the female pelvis is shorter than that of a male’s, the pubic arch is narrower and finally the pelvic wings are more flared. [5–10, 12–16]

The wider dimension of the female pelvis produces a constellation of kinesiologic changes starting with a decrease of femoral angle and varus hips (a.k.a. anteversion). [5–10, 12–14] These changes significantly increase the quadriceps angle (Q angle) of the female femur by as much as 15% higher than that of a male. [5] This cascades into a greater valgus at the knee, internal tibial rotation and foot pronation. [5, 7, 8–10, 12–14] Several authors declare that the tightness of the quadriceps muscle and/or inadequate development of the vastus medialis may also be present. [14] Additionally, researchers postulate an inverse relationship in quadriceps to hamstring ratio is a contributing factor to patellofemoral injuries. [8, 9, 12, 13] Ligament laxity, which is common in women, has been noted with controversy, as a predetermining factor to injury potential. [8, 9, 12–15]

The wider female pelvis has also been postulated to alter the carrying angle of the forearm and act an impediment in throwing activities. This proposed etiology has been met with dispute. [8, 9, 12, 13]


Factors Contributing to Musculoskeletal Injuries

Injuries of the musculoskeletal system, especially the patellofemoral region, are believed to be a direct result of pelvic and lower extremity anatomy unique to women. Injuries of the feet and shoulders may also occur. Stress fractures seen in athletic women often are an outward representation of a symposium of maladies. Underlying social and psychological reasons must be considered when evaluating an athletic woman. Social factors can contribute significantly to disorders seen in the feet as well as to stress fractures.

Issues of training and conditioning are important when evaluating female athletes for injury potential. Traditionally, men have had access to training coaches and equipment where women have not. Weight rooms and weight machines were historically designed for men. Quite frequently weight equipment, for example a leg press machine, has been designed to accommodate a male physique. Only recently have accommodations been made where exercise equipment is designed specifically for females. When women use exercise equipment designed for the male physic she may compromise posture and form, Even if the equipment is set at the lightest weight. This too may be arduous for the woman’s physic and precipitate injury causing structural faults, myofascial sprain/strain or repetitive microtrauma.

Injuries to the Patellofemoral Region

Injuries to the patella are common to the female athlete. Fundamental biomechanical differences appear to be the most conclusive cause. Injuries to the anterior cruciate ligament, miserable mal-alignment syndrome and patella instability affect female athletes at a greater rate than males. [8, 9]

Ligament laxity, which often correlates with the female hormones estrogen, progesterone and relaxin (most prominent during pregnancy) has been sited as a contributing factor to patellofemoral injuries. [7–9, 12, 13] Although flexibility can be acquired, as often seen in gymnast and dancers, sources report a normal lumbar extension in a female of approximately 10 degrees higher than that in men. [17] This divergence is reported as a result of an elongated anterior longitudinal ligament. [17] Christensen sites a New Jersey study that stating the vulnerability of the ACL being due to the small anatomical space and its’ inherent weakness common to women. Other researchers postulate overuse, improper conditioning, imbalance between the quadriceps/hamstring muscles, altered biomechanics from an increased quadriceps angle, and pronation or improper shoes as predisposing factors. [6–9, 12–14] The true epidemiology of patellofemoral injury is still ambiguous though many authors concur that the increased pelvic width and resulting increased Q angle are the foundation to these injuries. It is plausible that the culmination of these factors is what predisposes women.

Patella Instability

Patella instability, which often occurs following a trauma to the knee, has been diagnosed in female athletes without direct insult, frank subluxation or chronic episodes of dislocation. Normally when patella instability occurs, acute effusion follows. Researchers have identified female athletes who have presented with patella instability absent a history of acute trauma, chronic subluxation or dislocation. Exogenous factors such as conditioning, strength or trauma as well as endogenous factors such as ligament laxity ligament size, and mal-alignment can cause patella instability. [7–9, 12–14] Evidence substantiating these etiologies still remains inconclusive, though research indicates a high propensity for dislocation injuries occurring from non-direct trauma to the knee. [8, 9]

Patellofemoral Pain Syndrome: Miserable Malalignment Syndrome

Patellofemoral pain syndromes, more common to women than men [6, 8, 9, 12–14], are often associated with malalignment of the lower limb. [9] Several variations in limb alignment exist. Collectively they are termed Miserable Malalignment Syndrome. Miserable Malalignment Syndrome describes patella pain resulting from aberrant alignment, subluxation of the knee, or lateral tracking. Lateral tracking of the patella and miserable malalignment disorders have been positively associated with femoral anteversion, internal rotation of the femur, external tibial rotation, and pedal pronation. [6, 8, 9, 12–14] Altered alignment associated with this may result in an increased Q angle, lax ligaments and possibly patella alta. [6–9, 12–14]

Clinically patients can present without pathological findings or documented instability. [6–9] Limb malalignment has been positively associated with the development of " miserable malalignments syndrome". James, MD correlates an etiology of chondromalacia patella to malalignment in the lower extremities. He notes that that although remote from the patella, abnormal forces can be transmitted to the knee and eventuate in degeneration. [7] Clinically these patients should be examined for limb and spinal mal-alignment.

Patellofemoral stress syndrome in female athletes is concurrent with anatomical differences seen in the female anatomy and may result in lateral tracking of the patella. [14] A wide pelvis, increased valgus of the knee, increased femoral anteversion and an underdeveloped vastus medialus muscle are predisposing factors. [14] Blunt trauma, chondromalacia patella, and the injury to the extensor mechanism of the knee may present as retropatella pain. [8, 9]

Rehabilitation should include strengthening of the quadriceps, stretching and strengthening the hamstrings, orthodics, correction of foot alignment, and other malalignments in the spine. [6, 8, 9, 14]

Injury of the Anterior Cruciate Ligament

Injury rates to the anterior cruciate ligament have been found to be significantly greater in female athletes, recreational or competitive, than in males. Epidemiology for the mechanism of injury have been postulated to include; excessive foot pronation [12, 13, 18], a small and comparably weaker ACL to men. Other postulated causes include its’ location in a more confined space and with less leeway [15], lack of muscle strength or improper muscle conditioning, cyclic estrogen secretions [15] joint laxity [7, 12, 13] limb malalignment [8, 9, 18], interchondylar notch size, [12, 13], lower hamstring to quadriceps ratio [12, 13]; internal rotation of the knee [12, 13, 18], and decrease articular circumference. [6] Though it remains unclear there is an almost uniform agreement that pedal pronation and subsequent abnormal tibial rotation contribute to injuries of the ACL that are non-traumatic and repetitive in nature. Chronic abnormal biomechanics of the foot and ankle, such as an arch collapse and excessive pronation can cause abnormal internal rotation which " preloads" the ACL, Continued beyond the contact phase, the tibia will remain internally rotated. This abnormal tibial rotation transmits excessive forces upward in the kinetic chain to the knee joint producing medial knee stress, and lateral tracking patella. [18] Studies have found excessive passive rotation of the tibia in persons who were pronated as compared to non-pronated. [18] Hyperpronation of the foot and ankle has been positively identified as a significant risk factor in ACL injuries. [18]

Iliotibial Band Friction Syndrome (ITBFS)

Iliotibial band friction syndrome is an injury of overuse most frequently diagnosed in female runners. Repetitive stress common to running is the most widely accepted causative factor. A review of literature suggest the increased Q angle, leg length discrepancy and forefoot varus as causative. [12, 13] Additionally, pelvic width and prominence of the greater trochanter have been sited. [14] Contended also is the affects that the wider pelvis with a more prominent greater trochanter often seen in women can increase the span of the iliotibial band. Taughtness can result with increased friction that can irritate the bursa between the band and trochanter. The bursa becomes inflamed and produces pain. The iliotibial band can also subluxate and cause a snapping, painful audible. This is refered to as the "snapping hip syndrome". [6]

Running has been undeniably associated with the occurrence of ITBFS, especially downhill running. [12, 13] The decrease in knee flexion angle at foot strike predisposes runners to ITBFS. Decreased knee flexion places the iliotibial band in the "infringement zone " of the lateral epicondyle thereby increasing the friction of the iliotibial band. They also noted a direct relationship between ITBFS and running speed as a decrease motion in knee flexion occurs simultaneously to an increase in running speed. [12, 13] Literary review indicates dichotomy in findings.

Foot Injuries Common to Females

Women have notoriously been subject to many social pressures. Footwear, one of the many peer-pressured socialites, has begotten women with various residual problems. Disorders of the feet are not exclusive to the female population, but due to the many unnatural types of footwear, women are plagued the most. The development of disorders in the feet still remains speculative though heredity as well as types of footwear appear to be the most prominent etiologies Genetically women have a tendency for a more prominently developed first and fifth metatarsal heads as compared to the second and fourth. [14] Shoes that are overly narrow, have high heals, and those that fit improperly can irritate an existing condition or cause the development of one. [8, 9, 14] Excessive pressure is imparted on the bursar, eventually forming a bunion with the possibility of an adaptive hallux valgus deformity developing. Shoes with high heels thrust weight bearing onto the metatarsal heads accentuating pressure placed on them. The forward thrusting and attempt assume proper gait actually alters posture and disrupts the normal phases of gait which can irritate a bunion or encourage the development of a new bunion. A patient experiencing irritation to a bunion may assume an antalgic gait. This attempt to ameliorate pain disrupts posture and alters proper biomechanics. Aberrant intersegmental spinal dysfunctions can ensue. Clinically patients may complain of low back, neck, or hip pain, or possibly other somato-visceral complaints. [19, 20]

Patients with marked pronation can exacerbate an existing bunion and impart excessive pressure on the metatarsal heads. [8, 9] Offending footwear should be identified and removed while correcting for dropped metatarsal heads. Pain from this can alter gait affecting the pelvis and spine, which are not able to move smoothly through the phases of gait. Custom made orthotic foot wear is a viable treatment option concurrent with restoration of proper interspinal segmental mobility. [8, 9, 14, 18, 21]

Advising patients to following these guidelines when purchasing shoes may aid in abating these obstacles: Buy shoes at the end of the day, shop when the staff is accessible to assist you; wear socks or foot coverings that will be worn with the shoe; size the shoe based on the larger of the feet; keep a thumbnail distance between the end of the toe and the end of the shoe. [8, 9] Women should also pay attention to the wear on their shoes. Athletic shoes should be young, with ample cushion and arch support.

Stress Fractures

Stress fractures in women are more complicated than those diagnosed in men. Stress fractures in athletic females are multifactoral. Repetitive overuse, repetitive mechanical loading , menstrual irregularities affecting estrogen levels and deprivation of essential nutritional needs such as calcium and boron contribute significantly to stress fractures. Isolated treatment of stress injuries would focus on repair and rehabilitation. In women who are physically active, stress fractures may be an ominous red flag declaring an underlying health disorder. Stress fractures normally occur in weight bearing bones; tibia, femur, fibula, metatarsal heads, and sometimes the pelvis. [14] Women that engaged in long distance running and dancing, swimming and other sports that encourage a lean physic are at a higher risk for developing a stress fracture. Stress fractures of the spine usually affect the pars interarticularis and the vertebral endplates (apophysitis). Apophysitis is commonly seen in gymnasts. The repetitive hyperlordotic positions load the pars at an overbearing rate, eventually fatiguing the pars and fracturing. Repetitive hyperextension can also cause spondylosis. Gymnasts produce excessive axial loads on the spinal vertebrae. Dismount and jumping activities cause the gymnast/athlete to land on both feet simultaneously causing axial pressure to get transmitted through the spine. With repetition of this activity apophysitis ( inflammation of the vertebral end plates) can occur.

Biomechanical stressors of a repetitive nature eventually fatigue the pars interarticularis causing an ismic sub type II fracture. Accurate diagnosis is made through retrogram. [22] Spondylolysis is not exclusive to female athletes. Pars fractures of this nature have also been identified in newborns and young children. Postulated etiologies sited include early walking and the use of baby bouncing devices. Both prematurely stress the lordodic curve into a hyperlordotic position . Pars fractures are not gender specific, though frequently diagnosed in young females. This is most likely due to the numbers of females to males that participate in the sport. Pars fractures have been identified in both genders and have been diagnosed in contact sports , especially teenagers participating in football. [22] A treatment protocol consisting of rehabilitation, rest and restoration of the intersegmental spinal motor unit should be implemented. Maintaining proper alignment restores aberrant biomechanical function and helps control pain. [4, 13] Restoration of kinesiology is found to normalize sympathetic output, thereby normalizing physiology and health. [19]


The Female Athlete Triad

The female athlete triad is a condition consisting of disordered eating, amenorrhea (delayed onset of menses by age 16 years) and premature osteoporosis. The female athlete triad is an outward manifestation of compromised health in women. Women engaging in excessive exercise, who alter or increase exercise training dramatically with concomitant calorie restriction are at highest risk. As physical demands increase nutritional needs are increased. With calorie restricting and exercise, sub-clinical vitamin/mineral deficiencies, specifically calcium and boron can ensue. Rigorous exercise has been positively linked to decreased calcium and decreases in blood estrogen levels. [5, 6–10, 14] Patients diagnosed with the triad are usually found to have decreased estrogen production, excess cortisol production and suppression of gonadotrophin releasing hormone. Researchers theorizes that GnRH (gonadotrophin releasing hormone) production is inhibited through exercise which blocks hypothalamic function. Innadequate hypothalamic function interferes with the production of GnRH. [12, 13]

Menstrual irregularities, such as amenorrhea, may result from inappropriate caloric intake coupled with exercise. This has been defined as an ‘energy’ drain that subsequently causes a low T3 with resultant amenorrhea. [12, 13]

Amenorrhea,( 0 to 3 menstrual cycles per year) oligomenorrhea ( cycles lingering more than 36 days or having four to nine menstrual cycles per year) and other menstrual irregularities can be associated with excessive exercise. Delayed menarche, secondary amenorrhea (absence of 3–6 menstrual cycles per year), and oligomenorrhea can interfere with adequate estrogen production. Hypercortisolemia seen with excess exercise and decreased calorie intake has been positively identified as an impairment to bone density production and to alter pituitary-hypothalamic function. Concomitant nutritional depletion, hypercortisolemia and inadequate estrogen production cause premature osteoporosis common to those diagnosed with the female athlete triad. Athletic osteoporosis and resultant stress fractures is a direct result of estrogen deficiency from delayed menses and amenorrhea. [23, 24] The loss in bone density from athletic osteoporosis is irreversible. [24] Normal accretion of bone mineral density occurs until the mid-thirties. [23] According to the literature reported by Warren and colleagues, osteopenia in young exercising women with amenorrhea or oligomenorrhea impairs bone formation due to its’ linear relationship of estrogen deficiency, Ardent postulates the association of caloric restriction as a concomitant factor to osteopenia in young exercising women.

There has been indepth research on the relationship between hypoestrogenemia and musculoskeletal injuries with the use of a questionnaire. The questionnaire revealed that stress fractures occurred at a rate four times greater in women with irregular menses than those who cycled regularly. [7] Studies of long distance runners showed that athletes with irregular menses were at a significantly greater risk (almost 50%) of developing stress fractures as compared to those with regular menstrual cycles. [7] Patient history should include an evaluation of menstrual regularity, prior stress fracture, exercise schedule (number of days/week, duration and intensity level) and diet. Following positive findings on a history, a bone densitometry should be ordered to rule out premenopausal osteopenia. For the chiropractic physician this is essential before initiating a care plan that includes osseous adjusting.

Upper Extremity Shoulder Injuries

Overhead sporting activities; swimming, volleyball, tennis or racquet sports, and throwing predispose women to rotator cuff and impingement injuries. Anatomically, women retain a greater risk for because of their shorter bones, hence, shorter arms than the average man. [5–9] In addition to their smaller stature, the articular surface of the glenohumoral joint is reduced. [6] Female patients involved with overhead activities must make more overhead strokes to accomplish the same task than their male counterpart. Increasing the number of strokes increases the number of repetitions, thus increasing the risk of overuse injury.

Increase ligament laxity common to females has been sited as predisposing them to injury. Some authors have disputed this concept. A resent study involving junior high and college athletes concluded that females were more flexible on all measurements. Measurements included flexibility of the shoulder, quadriceps, gastrocnemius, and the low back. [7] Laxity in the shoulder can present as an impingement syndrome. [8, 9] With increased shoulder laxity, upward and anterior migration of the humoral head in the rotator fossa can occur as one performs a range of motion activity. Female hormones such as progesterone, estrogen and relaxin are known to relax ligaments and muscles during pregnancy. It is possible that these hormones may accomplish this in a much smaller capacity when in the non-gravid state. [8, 9]

The integrity of the cervical spine can become compromised with an injury to the upper extremity. The impinged location which is in a confined space creates in limitations between the bony head of the humorus, the bony roof of the acromion, and the tight ligamentous arc of coracoid-acromion ligament. The rotator cuff muscles and its accompanying overlying bursar sac course through this region. Increased tissue irritation and edema will result in too much tissue underneath the coracoid acromial arc, with not enough space in forward flexion". [8, 9]

Evaluation and treatment of the following musclse are to be included in any rehabilitation program for shoulder injuries. The trapezious muscle, with its origins including the external occipital protrubance, the superior nuchal line, ligamentum nuchae, the spinous processes of the cervical vertebrae and thoracic vertebrae, inserts on the lateral 1/3^rd of the clavicle and the acromion process of the scapula, superior lip of the scapula, and the tubercle at the apex of the spine of the scapula. The trapezious muscle is involved with scapula motion, cervical motion and acts as an accessory muscle of respiration. [26]

The levator scapula muscle contributes significantly to shoulder/neck function. It originates from the cervical spine transverse processes and inserts on the medial aspect of the scapula between the superior angle and the root of the spine of the scapula. It primarily acts on the scapula but is involved in cervical extension. [16, 26] Rotator cuff muscles; supraspinatus muscle, infraspinatus muscle, teres major, and subscapularis are intricately involved with flexion of the arm and scapula motion. The supraspinatus originates in the supra spinous fossa and inserts on the greater tubercle of the humorus and shoulder joint capsule. The supraspinatus is involved with shoulder abduction and stabilization of the humoral head into the glenoid fossa.

The subscapularis originates at the subscapular fossa and inserts on the lesser tubercle of the humorus and shoulder joint capsule. It medially rotates the humorus and acts as a stabilizer. The infraspinatus muscle arises from the infraspinous fossa of the scapula to insert on the greater tubercle of the humorus and the shoulder joint capsule. Also acting as a stabilizer, it is involved in lateral humoral rotation. The teres major muscle, which medially rotates, extends, and adducts the humorus arises from the dorsal surface of the inferior angle and the lower third of the lateral border of the scapula to insert on the lesser tubercle of the humorus. [16, 26]

A shoulder injury therefore, cannot neglect the involvement of the trapezious muscle and the levator scapula muscle, primary cervical muscles. The scapula, a common denominator to each of these muscles, anatomically supplies either origin or insertion to each of these muscles. A rehabilitative program encompassing treatment to the glenohumoral joint and cervical spine would be recommended.

Weight Loss, Diet and Exercise

Weight loss for many women can be a constant battle. For those who are post partum it may represent a struggle they have not encountered before.

Fad or yo-yo dieting can destroy weight loss efforts. Born with a given number of fat cells, excessive eating can actually cause fat cell size to increase and gain weight. [27] Continued over-eating will eventually lead the body to develop more fat cells. Restricted calories will reduce the size of the fat cells but does not reduce the number therefore, losing weight becomes more difficult with each fad diet. As you restrict calories the body slows down metabolic rate to conserve energy and fat. A recent study identified rats that had lost weight and then regained the weight. With each weight loss and regaining their metabolic rate slowed down. [27]

Intense exercise can increase the risk of injury and probability of the female athlete triad, and can deplete the immune system. A study of marathon runners reveled a six times more incidence of colds and influenza than those not marathon running. [27] Along with depleting the immune system, vigorous exercise can actually increase appetite and food intake, as an adaptive response to conserve energy can slow metabolic rate. [27]

Moderate exercise may actually be more beneficial than intense exercise. A study of 102 sedentary women where divided into three groups. Each walked 3 miles 5x/wk at different speeds. The group who "strolled" lost more weight. This was due to the type of calories that were burned. The short intense exercise burns carbohydrates for quick energy. Longer exercise programs, he reports, allows the body to utilize other sources of energy. [27]

 

Postural habits women adopt can contribute to myofascial pain and spinal joint dysfunction.

Pocketbooks are usually carried over one shoulder (most often the dominant side); carrying a baby or child causes a constellation of spinal distortions; women will jet out their hip to assist in holding the child while shifting the contralateral thoracic and costal region out laterally; the use of cordless or wireless telephones encourages longer usage with repetitive and chronic upward lifting of the shoulder to the ear with ipsilateral lateral bending of the cervical spine. These are all postural habits which women may adopt and lead to myofascial pain and spinal joint dysfunction. Simple remedies to these habits would be to encourage her to use headphones, alternate her shoulder bag (if she will not convert to using a back pack or waist pack), and alternate sides she hold the baby and her phone use. Habit and comfort may interfere causing resumption of prior positions.

Educating patients regarding posture and ergonomics in child-care may prevent injury and decrease the occurrence of re-injury. Patients who are tending to children or working while fatigued often neglect proper lifting and bending techniques. Review the importance of proper ergonomics with them. Advise patients to bend there knees when lifting the child. Change the child at arms height to avoid a "hunched" position. Hold the child close to the body, when lifting. Lift with the infant/child held closely to the adult’s body and avoid twisting the trunk while lifting. Try to have diapers creams, powders and wipes ergonomically available. Whenever possible, use a foot rest under one or both feet while sitting or standing and tending to the child.

Puberty: Evaluating Teenage Girls

As young females begin to develop from pre-puberty through puberty, they change physiologically as well as anatomically. Breast tissue development may cause a young woman to become very self-conscious. This self-conscious state of mind can present in altered posture. Postural compromise may result in excessive strain on the thoracic spine from a forward rounding of the shoulders and flexion of the lower cervical spine with extension of the occiput on atlas. Uncorrected, a Heuter Volkman response may occur on the intervertebral disc and vertebrae resulting in a dowager hump and possibly a lateral thoracic curve. The Heuter Volkman response states that excessive pressure on a bone can cause resorption of that bone resulting in deformation. Clinicians should encourage their adolescent patients to maintain proper posture as often as possible. A Heuter Volkman response may also occur in seniors where they have a hyperkyphosis with or without a lateral bend.

Fibromyalgia: A female condition

The diagnosis of Fibromyalgia, according to the American College of Rheumatology diagnostic criteria was set 1990. [28] Such diagnosis was confirmed if the findings included persistent fatigue with generalized musculoskeletal pain persisting for at least 3 months duration. A total of eighteen tender points have been identified, whereby eleven must be present for an accurate diagnosis. Tender point sites are located in several regions bilaterally. They include: the suboccipital region, the area of c5c7, the upper traps, the supraspinatus,, the costovertebral junction of the second rib, 2cm distal to the lateral epicondyle, the gluteals, the greater trochanter, and medial fat pad of the knee.

Fibromyalgia, is a syndrome of chronic widespread pain, fatigue and stiffness that can be debilitating. [28] Some authors believe it is related to autoimmune antibodies, [29] depression, stress and possibly nutrition. Although a true etiology remains elusive, some researchers declare that a lack of REM sleep is the culprit. In conjunction to fatigue and pain, patients may describe symptoms such as headaches, irritable bowel syndrome, numbness, depression and anxiety. These patients also suffer from non-refreshing sleep and overall morning stiffness. Symptoms increased with stress, damp weather, in the morning and evening. [30] Fibromyalgia has a predilection for the female population at 10 to 20 times the frequency than seen in males. [28]

When diagnosing fibromyalgia, there are certain criteria or characteristic symptoms or complaints that must be met. Patients must experience more than three months of wide spread pain. Within the defined number of tender points, the patient must experience pain on palpation in 11 of the 18 specific locations. Four kilagrams of pressure is accepted as adequate for diagnostic purposes. [28] Fibromyalgia patients often display a lower threshold for pain including heat pain, pressure pain and pain tolerance overall. [31]

Obtaining an accurate diagnosis it is essential to rule out conditions including, hypothyroidism, lupus, rheumatoid arthritis, gout, systemic conditions, lymes disease and Ebntein Barr Virus. Proper diagnosis also requires the clinician be able to differentiate fibromyalgia from myofascial pain . Myofascial pain is elicited with certain movements. Pathogneumonic for myofascial pain syndrome are the trigger points. Discerning trigger points from tender points seen in fibromyalgia aids in diagnosis. Trigger points are hyperirritable locations within a taught band of muscle or muscles that when palpated will refer in a specific pattern. Unlike the tender points of fibromyalgia, which are widespread and non-specific. Tender points are located in areas of soft tissue, whereas trigger points are located in skeletal muscle tissue. ( Dr. Schieder) I refer readers to Travell and Simmons Myofacsial Pain and Dysfunction : The Trigger Point Manual.

Chiropractic and osteopathic manual medicine is supported for Fibroymalgia patients.( shneider) As reported by Dr. Scneider, Dr. Lewit declares that myofascial pain is largely the result of articular and muscular dysfunction. [30] Bogduct and Simmons, he states, demonstrated a correlation between certain referred pain patterns elicited from trigger points in the cervical muscles and scleratogenous patterns from zygapophyseal joints. Schneider also reported findings of Vernon et al that demonstrated relaxation of taught and tender bands associated with the correction of a subluxation. [30]


Clinical Gems Important to Treating Female Patients

Multiple Sclerosis:

Multiple Sclerosis is a disease of the nervous system, affecting twice as often in females than in males. It is a disabling disorder of chronic inflammation, demyelination and gliosis (scarring). Diagnosis can occur anywhere between the ages of fifteen to sixty years of age. Patients who reside in a more temperate climate appear to be at a higher risk for developing the disease. Research has determined that the prevalence increases as distance from the equator increases. Much speculation has been made regarding it’s etiology with the most accepted being autoimmune. Indirect evidence supports autoimmune disease as an etiology. [29] Other possibilities include viruses and certain environmental exposures. Samples of cerebral in multiple sclerosis patients contained higher levels of antibody titers than non-multiple sclerosis patients. This supports the theory that viral infection can precipitate the onset of multiple sclerosis. No specific virus has been isolated.

Demyelination and recurring gliosis causes plaquing in the white matter of the brain, the optic nerve, and spinal nerves renders. Clinical presentations can include episodes of weakness in one or more limbs, paresthesias, hypesthesia (numbness) or tingling in the extremities, dizziness, urinary dysfunction, neuromuscular impairments, visual difficulties, emotional issues and musculoskeletal dysfunction, cognitive dysfunction, ataxia, and dysarthria (scanning speech). Episodes encountered initially resolve but eventually recur with permanent damage. It is important to note that the clinical presentation may not coincide with the extent of plaquing. Mild symptoms may actually diagnose on MRI with extensive plaquing.

Wheelchairs, canes and other devices may be employed to maintain independence. The benefits of chiropractic and manipulative care reside in restoration of spinal fixation from altered gait, posture and use of orthosis as well as amelioration of pain and homeostasis of afferent and efferent neuron signaling. Most important to the patient, is to adopt a multidisciplinary approach to care.

Endometriosis

Abnormal distribution of endometrial tissue deposited within the abdominal cavity is known as endometriosis. It is progressive in nature and affects five to ten percent of women. [32, 33] Endometriosis can occur in women of any age once they have reached menses and are pre-menopausal. But is most often diagnosed between the ages of twenty five to twenty nine years old. [32, 33]

The most common symptoms reported with endometriosis are symptoms of dyspareunia, dysmenorrhea low back pain and infertility. Symptoms are most often felt premenstrual and at menses. Symptoms of this nature at other times of the menstrual cycle may indicate other pathological disorders and should be referred accordingly. Endometriosis should be considered in women who present with cyclic low back pain and or cyclic neurological deficits such as foot drop or extremity atrophy. Endometrial implants can deposit on the lumbosacral plexus. Patients who are unresolved by manual therapy should be referred to her gynecologist for evaluation to rule out endometriosis. [36]

Definitive diagnosis is made through exploratory laparoscopy. At this time if endometrial tissue is identifies it can be surgically removed. Correlation between pain and extent of disease is not linear. Patients with extensive endometriosis may experience no pain. Unsuccessful attempts to conceive may lead to a diagnosis of endometriosis.

Conversely women may report severe symptoms with mild amounts of ectopic endometriosis.

Medical intervention is directed at preventing ovulation. Hormonal therapy is successful and can ameliorate the discomfort associated with endometriosis, but may return once therapy is ceased. Surgery is known to provide the most relief and may last for quite some time and improve pregnancy rates. Women who are not concerned with childbearing may consider a bilateral oophorectomy or a hysterectomy. [32, 33]

Non-invasive options can incorporate both allopathic treatment and holistic treatment.

A diet of whole grain foods and grains can be beneficial. Patients may also benefit from soy. Soy should be avoided for all patients who are being treated for hypothyroidism as it will counteract medication. Avoiding caffeine, refined sugars, processed foods, additives and preservatives are considered healthy approaches to managing endometriosis.

Systemic Lupus Erythematosus

Ninety percent of women of that are diagnosed with Systemic Lupus Erythematosus SLE are of childbearing age. The etiology of the disease remains unclear though it is understood that cells and tissues are destroyed by antibodies and immune complexes. [29] Evidence supports a genetic predisposition with environmental factors such as, UVA and UVB rays, alp alpha sprouts and chemicals as flare up precipitators. Abnormal levels of hormones may also be indicated, whereby the metabolism of estrogen and androgenic hormones can manifest the onset or flare up of lupus. This theory is support by the population age that is affected. Lupus is most prevalent in women of childbearing age as compared to males of the same age. The comparison of post menopausal women to men of the same age reveals a narrowing in the ratio of women to men who are diagnosed with the disease. Lupus is known to affect the black female population the most.

Clinically a patient may report symptoms that are uni-systemic or multi-systemic. They can report symptoms of exacerbation and remittance. True remission occurs in approximately twenty percent of cases [29]

Systemic symptoms can include but are not limited to; fatigue, malaise, weight loss, fever, cutaneous irritation, renal disorder, ocular disorder, vascular, hematological and arthralgias.

Musculoskeletal manifestations, according to the authors of Harrison’s, are the one complaint that is reported by almost patients. They either report arthralgia or myalgias. There can be swelling of the proximal interphalangeal joints, the wrists, the metacarpalphalangeal joints, and the knees that can cause pain but is not necessarily congruent with the amount of swelling found. [29]

Diagnosis is difficult and requires including the clinical findings of a malar "butterfly" rash over the cheeks or bridge of the nose and ears. Patients with SLE are photosensitive. Sun exposed skin is susceptible to recurrences and flare ups. Other clinical signs may include mild cognitive dysfunction, nephritis from deposit of autoimmune antibodies, migraine like headaches, and optic neuritis. Hypothalamic function can also be impaired with declining renal activity. Antidiuretic hormones decrease in production thus decreasing activity of the hypothalamus. Patients can often suffer from depression and anxiety resultant mostly from the chronic nature of the disease than a chemical imbalance.

Systemic lupus can adversely affect the vascular system. Exposure to chronic circulation of autoimmune antibodies increases there risk for thrombosis. Evidence indicates that these autoimmune antibodies interfere with anticoagulation. Clotting can occur absent inflammation. These patients are better treated with anticoagulants in stead of anti-inflammatory drugs.

Myocardial manifestation of arrhythmias, sudden death, and cardiac failure can result from pericarditis. Pleurisy and pleural effusion is common to lupus patients and may result in pneumonia.

The gastrointestinal system can be affected with symptoms such as cramping, nausea, diarrhea and vomiting. Vasculitis of the intestines is the most severe and dangerous gastrointestinal condition. Symptoms of nausea, diarrhea, cramping and vomiting are magnified and acute. Immediate surgical intervention is suggested.

Diagnostic testing includes the ANA test, which is best for screening lupus patients. A negative ANA indicates a decrease chance of lupus as a diagnosis, but is not conclusive. A positive ANA supports a diagnosis of lupus but is not specific to lupus. ANA is also used to screen for viruses, inflammation, other autoimmune diseases and for certain drugs. All diagnostic testing must be considered in conjunction with the clinical findings.


Clinical Gems Important to Treating Female Patients

Menopause

Menopause and perimenopause can affect women as early as age thirty seven.

Menopausal women are most commonly confronted with concerns of osteoporosis, cardiovascular disease, urinary incontinence, and hot flashes. Patients can complain of a variety of symptoms including (but not limited to) anxiety, headaches, vaginal dryness, hot flashes, weight gain, irregular menstrual bleeding, dizziness, weakness, and heart palpatations. Weight bearing activity has been positively associated with retention of bone density. Physical activity may actually reduced the number of hot flashes as compared with those who were sedentary. [12, 13] Other benefits include enhanced mood, weight control, improved cognitive function, and a more restful sleep. [12, 13] It is also recommended that menopausal women supplement their diet with whole food derived calcium. Hormone replacement therapy is also mentioned as part of the treatment protocol for menopausal women.

Menopause urinary incontinence is common to women who exercise through menopause. Stress incontinence causes an involuntary loss of urine. Most often it is experienced with high impact activities and activities that increase intra-abdominal pressure such as weight lifting. [12, 13] These activities can weaken pelvic floor muscles. [12, 13] Presently, treatment protocols consist of Kiegal exercises, surgery, and pharmaceuticals. Research is lacking regarding chiropractic intervention. The muscles of the pelvic floor are innervated in large by the nerves from the sacral plexus, predominately S2, S3, and S4. [16] L1 and L2 spinal nerves contribute to the neurology of the urinary bladder. Chiropractic adjustments to the lumbar and sacral region could potentially aid in restoration of urinary continence. Aberrant biomechanics interferes with the delicate balance between the parasympathetic and sympathetic nervous system. [19] This, according to research, can be corrected through osseous manipulation. [19] At the time this article was written, no studies were located that focused on the abatement of urinary incontinence through chiropractic adjustment.

Menopause is a time of major life changes physically, emotionally and psychologically causing stress. A myriad of causes can be attributed to the onset of stress. Weight gain during menopause, often linked to the decline in estrogen loss overall reproductive hormonal changes can create stress to women who usually have a slender physique or have been able to manage their weight without difficulty. Life changes such as retirement from career, moving or downsizing a house, loss of a loved one, inability to conceive, retirement of a spouse where she may experience feelings loss of privacy and loss of freedom, empty nest syndrome, and reflection on ones own life accomplishments are stressors at different levels for each individual woman.

Stress is responsible for a cacophony of illnesses from the most obvious to the most obscure. Musculoskeletal presentations include muscle tension. headaches, tempromandibular joint pain, cervicogenic pain, rounded shoulder posture and a decline in immune function. Studies have illustrated that abnormal spinal functioning of the musculoskeletal system can cause hyper-sympathetic activity. [19] Hyperactive sympathetic activity affects the vasculature that that system innervates. [34] This can adversely affect the health of the organ system via its’ direct innervated by the sympathetic system and the vasculature.

Osteoporosis affects many American women menopausal and beyond. Causes include a decline in estrogen, a sedentary lifestyle or an excessive exercise regimen with limited caloric intake and nutrition.

Breast Cancer

Breast cancer, the most common form of cancer in women after skin cancer, is a proliferation of malignant epithelial cells. It is considered a genetic disease caused by the exposure of carcinogenic factors. [29] It is theorized that breast cancer is hormone dependent and is influenced buy genome, diet, and lifestyle. Most authors concur that women who consume a diet high in fat have a direct increased incidence in breast carcinoma and those who consume alcohol have an increase risk for breast cancer development. Medications, especially those that contain hormones influence breast cancer developement. Breast exams and mammography are extremely important to early detection of breast carcinoma.

The most commonly accepted risk factors are: age, 80% of cases occur after the age of forty; Gender females retain a higher risk of developing breast cancer over men; personal history: A personal history of breast cancer, ovarian cancer, endometrial cancer, colon or thyroid cancer may increase the risk of breast cancer development; menarche: The onset of menarche before age 12 increased exposure to breast cancer; Menopause, he onset of menopause after the age of 55 increases the risk of developing breast cancer; Nulliparity, women who have never been pregnant are a greater risk for breast cancer development than those who have; Birth of the first child after the age of 30yrs. [29]

Three of the most profound dates that can aid in ascertaining risk are:

1. Age of Menarche: Females who menarche at age 16 have a 50–60% less risk than those who menarche at age 12.

2. Age at first full term pregnancy: Patients who are nulliparid have an increased risk of about 40% as compared to those who have full term pregnancies at age 18.

3. Menopause: Women who experience early menopause, either naturally or surgically have a reduced risk. Women who menopause at age forty two, ten years sooner than the average menopause at age of 52 decrease their risk by 35%. There is a straight line increase in risk with each year until menopause, whereby the risk decreases. [29]

 The National Cancer Institute Recommendations for Early Cancer Detection suggests:

1. Regular mammograms beginning at age 40 years and every one to two years thereafter. At age fifty, every year.
   
   

2. Regular breast exams by a health care professional
   
   

3. Monthly self breast exams [35]

Breast self exams should be done once per month, at the same time of the month. It is important to use the pads of the fingers as opposed to the tips. The pads are more sensitive and will be able to detect any changes more readily than the tips of the fingers. Choose a day, two to three days after menses. The breasts are less likely to be swollen. Repeat each month at this time.

To do a self exam:

– Advise your patient stand in front of the mirror, breast exposed, with her arms at her sides. She should look for overall skin tone, texture and coloring. She should note any discharge from the nipple, and any puckering, dimpling or changes in skin.

– Next, continuing in front of the mirror, your patient should place both hands behind her head and press her arms forward. She should be looking for a personification of dimpling, puckering, skin texture. This posture will aid in determining any alterations in shape or contour of the breast.

– Continuing, she should then place both hands on her hips, rotating arms and shoulders in forward motion. Again she should be looking for any changes in texture, contour or shape of the breast.

– For the next step it is advised to have your patient perform this in the shower using water and soap. This allows the hands to gently glide over the skin and tissue. This exam is done with the ipsilateral arm of the breast being examined while placed over the head. With the contralateral hand, begin the exam at the outer edges of the breast Gradually work inward toward the nipple in concentric circular motion. Do not forget to palpate the Tail of Spence and the axilla. The patient should be feeling for any unusual masses or lumps. Some amount of lumpy texture is normal and is do to lobules and ducts in the breast. It is for that reason that performing the exam be done consistently and at the same time each month. Have patient repeat on the opposite side.

– Advise your patient, to gently squeeze the nipple to look for discharge.

– Repeat the previous two steps lying down. It is important that the patient have a flat back with a pillow or towel under the shoulder of the breast she is examining. This will aid in bringing out any lumps or palpable masses under the tissue.

Staging the cancer is primary for determining the treatment. Lifestyle and age are also considered before treatment can commence. Staging the cancer also aids in determining survival rate.

Early detection is the most important factor in breast cancer survival rates. [35]

Stage 0 has a 99% survival rate

Stage I has a 92% survival rate

Stage IIA has an 82% survival rate

Stage IIB gas a 65% survival rate

Stage IIIA has a 47% survival rate

Stage IIIB has a 44% survival rate

Stage IV has a 14% survival rate. [29]

Common treatment include surgical mastectomy and radiation.

Metastatic disease (breast, lung, prostate, thyroid, kidney and GI) can frequently affect the spine. Patients may present with back pain complaining that is a constant dull ache most often worse at night. Treating these patients for musculskeletal dysfunction can be accomplished as a co-treat patient. If the back pain is not abated by manual treatment and rest be sure to refer this patient to her primary care physician and to an oncologist for further evaluation.

Diagnosis of breast cancer usually occurs in women who are beyond menopause. But this is not exclusive to this age group and may be diagnosed earlier. Red flags include weight loss, a family history of breast cancer, a prior diagnosis of breast cancer, where a patient resides, lump in breast, night sweats or metatstatic disease.

Know when the patient had here most recent mammogram, encourage patients to get tested and to perform home self breast exams.

Some of the risk factors include; patients who are post menopausal, possibly those on hormone replacement therapy, maintain diets high in carcinogenic and those who lead inactive lifestyles; place of residence; have a family history of breast cancer; patients who have been diagnosed with a tumor of the breast.

Treatment protocols vary and are dependent on the stage of the cancer. Staging provides parameters to prognosis and guidance for an appropriate course of treatment. Primary breast cancer is breast cancer that originates in the breast, which may or may not include the lymph nodes. If the neoplasm involves the ducts, it is referred to as ductal cancer in situ. If it involves the lobules, it is known as lobule cancer in situ. Both are considered non-invasive tumors. [29]

Ductal cancer in situ and lobular cancer in situ can be treated with a mastectomy or a lumpectomy. Survival rate for either is equal in its outcome, making a mastectomy almost a personal choice. Tumor to breast ratio is an important component when considering a lumpectomy or a mastectomy. Breast conserving surgery retains a ten percent chance of the neoplasm recurring. [29] Left untreated, non-invasive ductal or lobular cancer in situ has one third of a chance of the tumor becoming invasive.

Estrogen and progesterone receptor tumors respond to endocrine therapy. Tumors with estrogen or progesterone or both receptors are less likely to recur as compared to those that do not have these receptors. [29] Tumors that are estrogen receptor positive and progesterone receptor negative have a thirty percent response rate to endocrine therapy. Tumors that are receptor positive for estrogen and progesterone have a seventy percent response rate to endocrine therapy. Tumors that are receptor negative for both have a rate of less than ten percent response to endocrine therapy. [29]

Chemo-radiation is often used to adjunct surgery or may be implemented alone. High dose chemotherapy with bone marrow transplant has recently been brought to the forefront of allopathic medicine for cancer patients.

In addition to avoiding carcinogenic factors, patients can be instructed to supplement their diet with a whole food vitamin and mineral. Genisten from soy is recommended. It acts to decrease tumor development. Shark cartilage can abate angiogenesis. Of course, exercise and meditative therapy can benefit.

Important idioms when treating the female patient:

Right Shoulder Pain in a female patient may be a viscerosomatic type pain. Patients who present with relentless right shoulder pain should be referred to their primary care physician for further evaluation. Gallbladder, liver and kidney infections could present this way. During their course of treatment, ask the patient if she is experiencing burning urination, is positive for the kidney punch test, is experiencing nausea, vomiting, fever or any unusual pain. Patients may deny these symptoms but still have infection. Refer your patient if there is little or no improvement after one week of treatments 3 times per week. If the patient is negative for infection it is prudent to have her follow up with an examination of the cardiovascular system.

Left Shoulder Pain in female patients could indicate cardiovascular disease. In addition patients may complain of referred pain into the left arm/ left jaw. Refer patients for an evaluation for cardiovascular disease. Refer these patients immediately. Call an ambulance in necessary. Document notes accordingly.

Oral Contraceptive Therapy depletes nutrients, and may increase the risk of stroke and may cause weight gain.

Important Idioms for treating the Female Patient

The geriatric female represents a population of women that as a whole can benefit from chiropractic care. Prior to commencing a treatment program, a review of the patient’s medical history must be completed. Inquire about medications, vitamin supplements, herbs and any medical condition they are being treated for. Attempt to acquire as much pertinent information prior to first treatment. Aim to uncover additional information in future visits to help understand the full medical, social and psychological picture.

• Senior patients who are diagnosed with osteoarthritis or spinal arthrosis should be adjusted gently using low amplitude adjustments, gentle traction, blocking, flexion/distraction, activator, cranial therapy or any gentle non-force technique. Therapy including moist heat, manual soft tissue manipulation, electric stimulation and vibration therapy which increases blood flow and aids in relaxing the muscle and soft tissue around the spine can greatly benefit a group that is predominately sedentary. Most often it is contraindicated to impart any manual therapy below the patellofemoral region. Risk of thrombosis exists.
  
  

• Senior and geriatric patients are often taking medications to alleviate pain associated with degenerative arthritis. Often these analgesics only mask the pain while the condition progresses. Encourage these patients to supplement their diet with whole food vitamins, essential fatty acids and chondroitant and glucosamine products. Keep supplements simple and to a minimum. These patients are usually on a budget and are already taking several medications. Write down instructions and give them or mail them to a member of the family.
  
  

• Geriatric patients often employ the use of walkers, canes and wheelchairs. These devices affect posture, ultimately contributing to a hyper kyphosis, and in some, degenerative scoliosis.
  
  

• Prescription medications for geriatric and senior patients are common. Many take more than one prescription medication daily. Side effects and drug interactions can hinder recovery and contribute to some of the complaints these patients may present with. The health care provider can offer to review the medications with the patient and a family member to eliminate possible side effects as a cause for their presenting ailment. Include a list of all medications in the patients file. Recommend to your geriatric patients to take a high quality multivitamin/mineral with probiotics and enzymes. Most often a pure whole food one-a-day is the most simple and most complete. Be aware that gastrointestinal compromise frequently occurs in senior patients where often a decreased HCl and a B12 deficiency are common.
  
  

• Loneliness and depression is very common amongst geriatrics. Some of the most common reasons include: empty nest syndrome (no children at home), feeling of not being needed or wanted, loss of home/independence, death of spouse, loss of touch actually being touched (hugged, caressed), cancer, metastatic disease, high blood pressure and chronic pain.

Manual therapy can benefit geriatric patients through the affects of touch. Offering them a listening ear can also provide a means for geriatric patients to heal.

Important Idioms for Treating a Female Patient

Doctor Patient Relationship

The development of a doctor/patient relationship should be professional with all work being well documented. Male doctors should have an assistant or office personnel in the room when treating or examining female patients. This is especially important if the exam/ treatment rooms have their doors closed. When examining an adolescent female, you may want to present her with personal questions without parents in room unless given permission by the patient.

As with all patients the most important skill you can offer is to LISTEN! LISTEN!LISTEN! When in doubt, ask a colleague, research the information and refer out when necessary.

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