Most of us have suffered from back pain at one time or another. It often occurs after over-doing a physical task, like fall yard work, winter snow shoveling, working on the car, cleaning the house, and so on. But there are times when identifying the cause of back pain can be difficult or impossible. Let’s take a deeper look at where back pain can come from…
Though activity-related back pain is common, many times a direct link to over-use is not clear. Micro-traumatic events can accumulate and become painful when a certain threshold is exceeded. (Think of the old adage “The straw that broke the camel’s back.”)
There are other less well-identified causes of back pain. One is called referred pain. This can be caused by an irritated joint or soft tissue not necessarily located in the immediate area of the perceived pain. For example, pain in the leg can result from an injured facet joint, sacroiliac joint, and/or a disk tear (without nerve root pinch). This is called “sclertogenous pain.”
Internal organs can also cause back pain. This is called a “viscerosomatic response” (VSR). A classic example of this is when the right shoulder blade seems to be the source of pain when the gall bladder is inflamed. This pain can be located at or below the scapula next to the spine and the muscles in the area are in spasm and sensitive or painful to the touch. Also, VSR is often not worsened or changed by bending in different directions (unlike musculoskeletal / MSK pain). Without further testing, it’s easy to confuse this with a MSK or a “typical” back ache. Ultimately, a final diagnosis may require an abdominal ultrasound (CT, MRI scan, and other diagnostics are less frequently used).
Visceral pathology in the back pain patient presenting to chiropractors is reportedly rare, and according to one survey, only 5.3% of patients present with non-musculoskeletal complaints. Other common VSR pain patterns are as follows: Heart – left chest to left arm, mid-upper back, left jaw; Liver – right upper shoulder (front and back), right middle to low back, and just below the sternum; Appendix – right lower abdomen (may start as stomach pain); Small intestine – either side of the umbilicus and/or between it and the breast bone; Kidney – small of the back, upper tailbone, and/or groin area; Bladder – just above the pubic bone and/or bilateral buttocks; Ovaries – groin and/or umbilical area; and Colon – mid-abdominal and/or lower quadrants.
Another challenge to diagnosis is cancer in the spine, which can be primary or metastatic (from a different location). Thankfully, this is very rare. A history of unexplained weight loss, a past history of cancer, over age 50, nighttime sleep interruptions, and no response to usual back care may lead a doctor to recommend tests to determine if cancer is present in the spine.
Bottom line: When patients present with back pain, chiropractors have been trained to look for these less common but important causes of back pain. They get “suspicious” when the “usual” orthopedic tests do not convey the usual responses seen with mechanical back pain. In these cases, they work with primary care doctors to coordinate care to obtain prompt diagnostic testing and treatment.
We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs. If you, a friend, or family member requires care for back pain, we would be honored to render our services.
Successful evidence-based chiropractors continually leverage new studies to improve their clinical decision-making. ChiroUp helps me by scouring fresh literature to mine out useful best practice data. This month, we’ve summarized more than a dozen studies for your review.
1. A new (very large) European Spine Journal Study examined the risk of acute lumbar disc herniation requiring early surgery in patients who visited a chiropractor vs. those who visited a PCP:
“The risk for acute LDH with early surgery associated with chiropractic visits was no higher than the risk associated with PCP visits. Both chiropractic and primary medical care were associated with an increased risk for acute LDH requiring ED visit and early surgery. Our analysis suggests that patients with prodromal back pain from a developing disc herniation likely seek healthcare from both chiropractors and PCPs before full clinical expression of acute LDH.”
P.S. Abundant research has revealed a similar conclusion for the relationship between cervical manipulation and stroke. Click here to download a helpful patient education handout regarding the safety of neck manipulation.
Hincapié, C.A., Tomlinson, G.A., Côté, P. et al. Eur Spine J (2018) 27: 1526.
2.A systematic review of carpal tunnel syndrome research comparing surgical vs. non-surgical outcomes found: “No significant differences at 3 or 12 months” in terms of functional status, symptom severity, and nerve conduction outcomes. Interestingly, the surgical patients experienced greater improvement at 6 months, but not before or after.
Qiyun S. et al. Comparison of the Short-term and Long-term Effects of Surgery and Nonsurgical Intervention in Treating Carpal Tunnel Syndrome: A Systematic Review and Meta-analysis. Hand. 2018 Jul 1:1558944718787892. [Epub ahead of print]
3.A study of more than 500 pregnant women found: “If both P4 and ASLR tests were positive mid-pregnancy, a persistent bothersome pelvic girdle pain of more than 5 days per week throughout the remainder of pregnancy could be predicted.”
Malmqvist S, Kjaermann I, Andersen K, et al Can a bothersome course of pelvic pain from mid-pregnancy to birth be predicted? A Norwegian prospective longitudinal SMS-Track study BMJ Open 2018;8:e021378.
4. A systematic review found no correlation between LBP intensity and the degree of MODIC degenerative change in the lumbar spine.
Herlin C et al. Modic changes—Their associations with low back pain and activity limitation: A systematic literature review and meta-analysis. PLoS1 2018 Aug 1;13(8):e0200677. doi: 10.1371/journal.pone.0200677. eCollection 2018.
5. According to a systematic review with meta-analysis in the journal Physiotherapy: “There is very low evidence to support the use of trigger point dry needling (TDN) in the shoulder region for treating patients with upper extremity pain or dysfunction.”
Hall, Michelle Louise et al. Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systematic review with meta-analysis. Physiotherapy , Volume 104 , Issue 2 , 167 – 177
6. A JMPT study of 82 cervicogenic headache patients found, “upper cervical spinal mobilization increased cervical range of motion and induced immediate headache relief.”
Malo-Urriés, Miguel et al. Immediate Effects of Upper Cervical Translatoric Mobilization on Cervical Mobility and Pressure Pain Threshold in Patients With Cervicogenic Headache: A Randomized Controlled Trial. Journal of Manipulative & Physiological Therapeutics, Volume 40 , Issue 9 , 649 – 658
7. A study of more than 6000 chiropractic patients revealed that few (5.4%) of the chiropractic patients used narcotics for their chronic pain, which is substantially lower than the 45% to 60% use typically found in chronic LBP populations. Additionally, if chiropractic care was no longer a covered insurance benefit, 30% of patients would continue as is, 61% would go less often, and only 7% would discontinue care.
Herman, Patricia M. et al.Characteristics of Chiropractic Patients Being Treated for Chronic Low Back and Neck Pain. JMPT 2018 Aug 15. [Epub ahead of print]
8. “Opioids are no more effective than non-opioid medications in the treatment of acute and chronic low back pain.”
Wertli, M.M. & Steurer, J. Pain medications for acute and chronic low back pain. Internist (2018). 2018 Aug 16. doi: 10.1007/s00108-018-0475-5. [Epub ahead of print]
9. A new article in the Journal of Family Practice endorsed a select group of therapies that show “good-quality patient-oriented evidence” for managing chronic low back pain. The journal advised physicians to:
10. A recent spine Journal study was “the first to measure facet gapping during cervical manipulation on live humans. The results demonstrate that:
Anderst WJ et al. Intervertebral Kinematics of the Cervical Spine Before, During and After High Velocity Low Amplitude Manipulation. The Spine Journal Available online 22 August 2018
11. A study of 100 fibromyalgia (FM) patients found recurrent “electrodiagnostic features of polyneuropathy, muscle denervation, and chronic inflammatory demyelinating polyneuropathy (CIDP)”.
Caro XJ, Galbraith RG, Winter EF. Evidence of peripheral large nerve involvement in fibromyalgia: a retrospective review of EMG and nerve conduction findings in 55 FM subjects. Eur J Rheumatol 2018; 5: 104-10.
12. A study of 40 collegiate athletes found that application of elastic therapeutic tape over the gluteus medius “improved strength immediately after taping (and) it was maintained even on the third day.” Hip taping also generated short-term correction of dynamic knee valgus.
Rajasekar, Sannasi et al. Does Kinesio taping correct exaggerated dynamic knee valgus? A randomized double blinded sham-controlled trial. Journal of Bodywork and Movement Therapies , Volume 22 , Issue 3 , 727 – 732
Let’s first look at the anatomy of the neck in order to better understand the structures of the cervical spine that can generate pain. Starting at the back of the spine, the facet joints allow us to move our neck and head in all directions, and each facet joint is surrounded by a joint capsule that is rich with nerve endings and when swollen, can generate pain both locally and radiating.
One study of volunteers with existing neck pain looked at the various pathways that pain travels when investigators injected each individual facet joint capsule with normal saline solution. Interestingly, the subjects felt pain in parts of the body other than just the neck. For example, injecting the C6 facet joint capsule consistently reproduced radiating pain down the arm into the thumb side of the forearm and hand, similar to when a disk herniates and a nerve root is pinched. The primary difference was that a deep aching pain occurred in this area, as opposed to a more geographically well-defined pathway when a disk ruptures and pinches a specific nerve root.
The intervertebral disks are small shock absorbers that lie between each vertebral body. These disks are sort of like a jelly doughnut, which can sometimes leak out and pinch a nerve root producing pain (as well as numbness, tingling, and even weakness) that radiates along the course of the nerve.
Poor posture is perhaps one of the most common causes of neck pain. The muscles in the chest tend to be stronger than those in the upper back and pull the shoulders forward resulting in forward head carriage with protracted shoulders. For each inch of forward head shift, an additional ten pounds is added to the weight of the head, which already weights around ten to twelve pounds. Hence, a five-inch forward head carriage places an additional 50 pound load on the upper back and neck just to hold the head upright!
Doctors of chiropractic are trained to identify these faulty postures and track down the pain generator(s) when a patients presents with neck pain. Through patient education, spinal manipulation, mobilization, exercise training, modalities, and more, chiropractors can greatly help those struggling with neck pain!
Content Courtesy of Chiro-Trust.org. All Rights Reserved.
For patients with chronic low back pain (cLBP), treatment guidelines recommend a non-surgical approach as the FIRST-LINE treatment. Ideally, the goal would be to avoid an initial surgery unless it’s absolutely indicated. That means, unless there is loss of bowel or bladder control or retention (which represents a medical emergency) or if there is progressive neurological motor and sensory loss, one can safely avoid surgery and conservatively manage the condition.
Interestingly enough, a systematic review of the results from three randomized controlled studies carried out in Norway and the United Kingdom found the outcomes or results between the surgical fusion vs. non-surgical treatment of patients with cLBP showed NO DIFFERENCE at an 11-year follow-up!
Studies have shown chiropractic to be highly beneficial for acute and chronic low back pain cases. In one study, researchers reviewed data on 72,326 cLBP patients in the Medicare system who received one of four possible treatment combinations between 2006 and 2012: 1) chiropractic only; 2) chiropractic followed by conventional medical care (CMC); 3) CMC followed by chiropractic; 4) CMC alone.
The research team found that chiropractic care alone (group 1) resulted in the lowest costs, and these patients had lower rates of back surgery and shorter episodes of care.
The group receiving CMC alone (group 4) had the highest costs, with the second and third groups being similar—both costing less and being more effective than CMC alone.
The conclusion of the study reads, “These findings support initial CMT [chiropractic manipulative therapy] use in the treatment of, and possibly broader chiropractic management of, older multiply-comorbid cLBP patients.”
Chronic pain is frustrating. Back pain and neck pain can pop up as the result of an injury or from an existing condition, but a lot of times our daily activities are to blame. Here are six common everyday activities that you may not realize could be causing your pain.
1. Driving – Driving for long periods of time is sure to generate some stress on your lower back, especially if you’re not using correct posture. If you have a long commute to and from work or you are required to drive for extended periods, consider purchasing a lumbar pillow to place behind your back for added support. And always sit up straight with your back completely against the seat.
2. Sleeping – Another culprit of back and neck pain is your sleep position. If you’re waking up with a sore back or neck, consider altering your sleep posture. Stomach sleepers tend to have the most complaints because that position places stress on your spine - especially your neck, since you must turn your head to breathe. We encourage you to sleep on your back with a pillow under your knees, or on your side with a pillow between your knees.
3. Sitting at a desk all day – Studies have proven that sitting for prolonged periods of time is detrimental to our health. Combat your sedentary day by moving more. Take small walking breaks every 30 minutes and use proper posture at your workstation. You may also want to consider using a standing desk.
4. Using your phone or tablet – Repeatedly looking down at devices throughout the day puts excessive stress on your neck, causing a condition we refer to as “Text Neck”. Limit time on your devices and when you must use your phone or tablet, hold the screen at eye level to prevent hunching over.
5. Carrying heavy bags – Whether you tote around a backpack throughout the day or have a heavy purse, your neck and spine can be at risk from the excessive weight. For backpacks, we recommend using both straps and keeping the pack as close to your body as possible. You could also opt for a rolling bag to help save your back. For purses, only bring with you what you’ll need for that day, and be sure to switch arms often.
6. Doing chores – Putting clothes in the washer and dryer, loading and unloading the dishwasher, vacuuming, and all life’s other necessities are possible precursors to back pain from repeated bending and twisting. The key to preventing pain is always to be aware of your posture and work on correcting it whether you’re standing, squatting, bending over, or carrying heavy loads. One trick is to imagine that you have a fluorescent light tube strapped over your spine, from your head to hips. Try not to break the bulb when you move.
If you’re one of the 90% of people that end up experiencing back pain at some point in your life, contact us to help you pinpoint the exact cause and develop a treatment plan that helps you recover quickly.
Summer is winding down, and families across America are gearing up for the beginning of a new school year. Help your kids (or yourself) start the year off right by considering some of our healthy back-to-school tips.
Although backpacks are practical, carrying around heavy books and supplies every day can cause discomfort and injury over time.
Be sure to do a quick backpack check:
Encourage your child to practice good posture when sitting in the classroom. Hunching over the desk for hours every day is sure to cause discomfort.
To sit at a desk correctly, they should:
Safely Return to Sports
Back-to-school also means back-to-sports for many kids. Remember that if your child was inactive in their sport for a couple of months, they might need to ease back into it. Always encourage them to warm-up beforehand, stretch afterward, and keep their workouts reasonable for their conditioning level and age.
By being proactive in your child’s health, you can help prevent problems. If your child does experience back, neck, head, or joint pain this school year, please give us a call at 772-286-5277.
Spinal manipulation is reaching a tipping point in the United States as a well-accepted treatment for Low back pain and disability. There are abundant studies demonstrating the benefit of SMT as a stand-alone treatment for LBP; however, manipulation, when combined with exercise has even better results. (1,2) To date, most studies have focused almost solely on adult populations. There are very few studies analyzing the treatment of children or adolescents with LBP. (3) And for studies of adolescents, there have been no randomized trials utilizing manipulation as a potential strategy. Many chiropractors treat adolescents with LBP pain on a daily basis. So, is manipulation and exercise beneficial for adolescents?
Chiropractic treatment of adolescents with LBP is growing. In fact, twelve percent of children age 4-17 utilized complementary healthcare approaches. SMT is strongly recommended in the treatment of LBP for adult populations. However, management of children suffering from LBP does not have a widely accepted treatment algorithm. There is an urgent need for non-pharmacologic LBP treatment options, especially in this young population. Evans et al. set out to answer the problem in a multi-center randomized trial comparing 12 weeks of spinal manipulative therapy (SMT) combined with exercise therapy (ET) to exercise therapy alone.
“For adolescents with chronic LBP, spinal manipulation combined with exercise was more effective than exercise alone over a 1-year period, with the largest differences occurring at 6 months.” (4)
Participants included 185 adolescents aged 12-18 with chronic LBP. The primary outcome was LBP severity at 12, 26, and 52 weeks. Secondary outcomes included disability, quality of life, medication use, patient-rated and caregiver-rated improvement, and satisfaction. Adding SMT to ET resulted in a larger reduction in LBP severity over the course of one year. The group difference in LBP severity (0-10 scale) was small at the end of (12 weeks) treatment but was larger at weeks 26 and 52 weeks. At 26 weeks, SMT with ET performed better than ET alone for disability and improvement. The SMT with ET group reported significantly greater satisfaction with care at all time points. There were no serious treatment-related adverse events.
Adolescents should not have chronic pain. Unfortunately, the increase in sports specialization and year-round training has led to an epidemic of children with LBP. On the opposite end of the spectrum, there is a growing number of school-aged kids with a sedentary lifestyle. Both extremes result in LBP and should be addressed. Many patients with LBP benefit from SMT to restore motion to the lumbar spine and surrounding areas. SMT is safe in adolescents and shows a more significant benefit than exercise alone.
Most likely, everyone reading this article has had a headache at one time or another. The American Headache Society reports that nearly 40% of the population suffers from episodic headaches each year while 3% have chronic tension-type headaches. The United States Department of Health and Human Services estimates that 29.5 million Americans experience migraines, but tension headaches are more common than migraines at a frequency of 5 to 1. Knowing the difference between the two is important, as the proper diagnosis can guide treatment in the right direction.
TENSION HEADACHES: These typically result in a steady ache and tightness located in the neck, particularly at the base of the skull, which can irritate the upper cervical nerve roots resulting in radiating pain and/or numbness into the head. At times, the pain can reach the eyes but often stops at the top of the head. Common triggers include stress, muscle strain, or anxiety.
MIGRAINE HEADACHES: Migraines are often much more intense, severe, and sometimes incapacitating. They usually remain on one side of the head and are associated with nausea and/or vomiting. An “aura”, or a pre-headache warning, often comes with symptoms such as a bright flashing light, ringing or noise in the ears, a visual floater, and more. For migraine headaches, there is often a strong family history, which indicates genetics may play a role in their origin.
There are many causes for headaches. Commonly, they include lack of sleep and/or stress and they can also result from a recent injury—such as a car accident, and/or a sports injury—especially when accompanied by a concussion.
Certain things can “trigger” a migraine including caffeine, chocolate, citrus fruits, cured meats, dehydration, depression, diet (skipping meals), dried fish, dried fruit, exercise (excessive), eyestrain, fatigue (extreme), food additives (nitrites, nitrates, MSG), lights (bright, flickering, glare), menstruation, some medications, noise, nuts, odors, onions, altered sleep, stress, watching TV, red wine/alcohol, weather, etc.
Posture is also a very important consideration. A forward head carriage is not only related to headaches, but also neck and back pain. We’ve previously pointed out that every inch (2.54 cm) the average 12 pound head (5.44 kg) shifts forwards adds an EXTRA ten pounds (4.5 kg) of load on the neck and upper back muscles to keep the head upright.
So, what can be done for people who suffer from headaches? First, research shows chiropractic care is highly effective for patients with both types of headaches. Spinal manipulation, deep tissue release techniques, and nutritional counseling are common approaches utilized by chiropractors. Patients are also advised to use some of these self-management strategies at home as part of their treatment plan: the use of ice, self-trigger point therapy, exercise (especially strengthening the deep neck flexors) and nutritional supplements.
Content Courtesy of Chiro-Trust.org.
All Rights Reserved
Many people seek chiropractic care when their back goes out or their neck tightens up. But how does this form of care actually work? What are the benefits of receiving chiropractic care for nerve dysfunction compared with other healthcare options? Let’s take a look!
First, let’s discuss how the nervous system “works.” We have three divisions of the nervous system: the central, peripheral, and autonomic nervous systems. The central nervous system (CNS) includes the brain and spinal cord, and it’s essentially the main processing portion of the nervous system. The spinal cord is like a multi-lane highway that brings information to the brain for processing (sensory division) and returns information back to the toes, feet, legs, and upper extremities from which the information originated (motor division). For example, hiking on a mountain trail or simply walking requires constant input to and from the CNS so we can adjust our balance accordingly and not fall. These “sensory-motor pathways” are essential and allow us to complete our daily tasks in an efficient, safe manner as information is constantly bouncing back and forth between the brain and the rest of the body.
The peripheral nervous system (PNS) includes a similar sensory/motor “two-way street” system relaying information back and forth from our toes/feet/legs and fingers/hands/arms to the spinal cord (CNS). And if this isn’t complicated enough, we also have “reflexes” that, for example, allow us to QUICKLY pull our hand away from a hot stove to minimize burning our fingers.
Reflexes allow the information to “skip” the brain’s processing part so quicker reactions can occur. The autonomic nervous system (ANS) includes the sympathetic and parasympathetic divisions that basically “run” our automatic (organ) functions like breathing, heart rate, digestion, hormonal output, and more. There is constant communication between the ANS, PNS, and CNS that allow us to function in a normal, balanced way… unless something disrupts them.
There are obvious conditions that interfere with this communication process that include (but are not limited to) diabetes (with neuropathy), frost bitten or burned fingers, peripheral nerve damage from conditions like carpal/cubital tunnel syndromes, thoracic outlet syndrome, and/or pinched nerves in the neck, mid-back, low-back spinal regions, as well as conditions such as multiple sclerosis (MS), Guillain-Barre Syndrome, after a stroke (spinal cord or brain), and after trauma with resulting fractures where nerve, spinal cord, and/or brain damage can occur. These are “obvious” reasons for delayed or blocked neurotransmission.
There are many other less obvious injuries or conditions that can result in faulty neuromotor patterns and nerve transmission of which chiropractic services can benefit. The “subluxation complex” is a term some chiropractors use to describe the compromised nerve transmission that may occur if a nerve is compressed or irritated due to faulty bone or joint position along the nerve’s course. Reducing such nerve compression typically allows for a restoration of function. A good illustration of this is a patient who suffers from a herniated disk in the neck with numbness and tingling down the arm to the hand. The goal of treatment (for all healthcare professionals) is to remove the pinch of the nerve.
To realize this goal, doctors of chiropractic utilize spinal manipulation and mobilization in addition to other non-surgical, non-drug approaches that may include exercises, nutritional advice, home-care such as a cervical traction unit, and other anti-inflammatory measures (ice, modalities like low level and class IV laser, electric stimulation, pulsed magnetic field, and more). Given the minimal side-effect risks and well-reported benefits, it only makes sense to try chiropractic FIRST and if you’re not satisfied, your doctor will help you find the next level of care.
Management of ankle inversion sprains requires two steps; each is equally important.
STEP 1—Move for Pain Relief
Early return to activity for acute inversion sprains is supported by the literature. Exercises and treatments that promote joint motion and early return to weight bearing for acute ankle sprains have proven more effective than immobilization. While grade III sprains (ligament rupture) may require immobilization, grade I and II ankle sprains should forego complete immobilization and instead focus on regaining full range of motion. In fact, early rehab and return to weight bearing will increase ankle range of motion, decrease pain, and reduce swelling sooner than immobilization.
In a study by Linde et al., 150 patients with inversion ankle sprains were treated with early motion and weight bearing. After one month, 90% of the patients treated with early motion and weight bearing demonstrated pain-free gait and 97% had increased work ability. (3) Early mobility exercises would typically include:
These four exercises promote balance and range of motion – specifically dorsiflexion, which is a key contributor to ankle injury. Patients who have lost an average of 11 degrees of dorsiflexion are five times more likely to suffer lateral ankle sprains. (4)
In office care should also include mobilization and manipulation for restoring function. Joint mobilization has been shown to decrease pain, increase dorsiflexion, and improve ankle function. (5) IASTM or transverse friction massage to the affected ligament may help mobilize scar tissue and increase pliability. Myofascial release may help release tightness or adhesions in the gastroc and soleus.
Knowing when to treat and when to refer is critical. Whitman’s clinical prediction rule identifies four variables to predict the success of manipulation and exercise for the treatment of inversion ankle sprains. (6) The presence of three out of four of the following variables predict greater than a 95% success rate for manual therapy and exercise:
STEP 2- Prevent Re-injury
The second step is shorter and easier than the first. The most crucial variable in the successful prevention of future ankle sprains is improving BALANCE. Balance training reduces the incidence of ankle sprains and increases dynamic neuromuscular control, postural sway, and joint position sense in athletes. (7) A study by de Vasconcelos et al. (2018) found that balance training reduced the incidence of ankle sprains by 38% compared with the control group. (7)
Two of the most common exercises used for balance and proprioception include the single-leg stance exercise and Veles. A simple explanation stressing the importance of balance training may be necessary to promote patient compliance.
Finally, we encourage our patients to start walking “normal” as soon as possible. As evidence-based chiropractors, we need to return patients back to their normal gait as soon as tolerable. Patients with foot and ankle pain will often favor a supinated gait in order to unload the soft tissues of the foot and arch in favor of their bony architecture on the lateral foot. The lateral column of the foot affords stability but at the expense of a very inefficient gait. Over an extended period, these patients may develop a Tailor’s bunion, i.e. 5th metatarsal head bursitis. However, in the case of ankle sprains, a rapid increase in activity may overload the metatarsal fast enough to cause a Jones Fracture. Return to normal gait will minimize these compensations.
Reprinted via permission from ChiroUp
Cliff Atwell, B.S., D.C.