Low back pain is a very common complaint. In fact, it’s the #1 reason for doctor visits in the United States! The economic burden of LBP on the working class is astronomical. Most people can’t afford to be off work for one day, much less a week, month, or more! Because of the popularity of hospital-based TV dramas over the past two decades, many people think getting an MRI of their back can help their doctor fix their lower back problem. Is this a good idea? Let’s take a look!
Patients will often bring in a CD that has an MRI of their lower back to a doctor of chiropractic and ask the ultimate question, “….can you fix me?” Or, worse, “…I think I need surgery.” Sure, it’s quite amazing how an MRI can “slice” through the spine and show bone, soft tissues, disks, muscles, nerves, the spinal cord, and more! Since the low back bears approximately 2/3 of our body’s weight, you can frequently find MANY ABNORMALITIES in a person over 40-50 years old. In fact, it would be quite odd NOT to see things like disk degeneration, disk bulges, joint arthritis, spur formation, etc.!
Hence, the “downside” of having ALL this information is the struggle to determine which finding on the MRI has clinical significance. In other words, where is the LBP coming from? Is it that degenerative disk, bulged disk, herniated disk, or the narrowed canal where the nerve travels? Interestingly, in a recent review of more than 3,200 cases of acute low back pain, those who had an MRI scan performed earlier in their care had a WORSE outcome, more surgery, and higher costs compared with those who didn’t succumb to the temptation of requesting an MRI!
This is not to say MRI, CT scans, and x-rays are not important, as they effectively show conditions like subtle fractures and dangerous conditions like cancer. But for LBP, MRI is often misleading. This is because the primary cause of LBP is “functional” NOT “structural,” so it’s EASY to get railroaded into thinking whatever shows up on that MRI has to be the problem.
Here is how we know this, when we take 1,000 people WITHOUT low back pain between ages 30 and 60 (male or female) and perform an MRI on their lower back, we will find up to 53% will have PAINLESS disk bulges in one or more lumbar disks. Moreover, we will find up to 30% will have partial disk herniations, and up to 18% will have an extruded disk (one that has herniated ALL the way out). Yet, these people are PAIN FREE and never knew they had disk “derangement” (since they have no LBP). When combining all of these possible disk problems together, several studies report that between 57% and 64% of the general population has some type of disk problem without ANY BACK PAIN!
Hence, when a patient with a simple sprain/strain and localized LBP presents with an MRI showing a disk problem, it usually ONLY CONFUSES the patient (and frequently the doctor), as that disk problem is usually not the problem causing the pain! So DON’T have an MRI UNLESS a surgical treatment decision depends on its findings. That is weakness, numbness, and non-resolving LBP in spite of 4-6 weeks of non-surgical care or unless there is weakness in bowel or bladder control. Remember, the majority of back pain sufferers DO NOT need surgery!
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.
Because the spinal cord is housed by the spine and the exiting nerve roots communicate with the autonomic nerves that basically run our organ function, maintaining alignment of the spine and pelvis is very important to minimize nerve irritation and subsequent health-related problems. The focus of this article is on leg length, its effect on our posture, methods of assessment, and treatment.
Leg length plays and important role in posture. When there is a difference in leg length, the pelvis cannot maintain a level position, and because the spine’s base is the pelvis, it cannot stay straight if there is a leg length discrepancy.
Doctors of all disciplines realize the importance of leg length, especially orthopedic surgeons as they consider a hip or knee replacement! There are many causes of leg length issues, and some include a genetic predisposition (inherited) or trauma during bone growth years.
From a treatment standpoint, a heel lift (with or without arch supports) can be placed into the shoe on the short leg side. Unfortunately, there is not a 1 to 1 mm correction of the leg length deficiency with heel lifts. In adults, it has been reported that about a 66% correction occurs, which means a 10 mm lift would result in around a 6.6mm leg length deficiency correction.
Many doctors have found that it is usually wise to GRADUALLY increase the amount of heel lifting, and so patients often start with a 5mm lift and at one week intervals, increase it to the next height, such as 7mm, followed by 9mm, and so on. At 12mm (0.5”), problems with the heel lift being pushed out of the shoe and/or sliding forwards in the shoe may prohibit the use of these thicker lifts after which point the bottom of the shoe can be built up by a shoe cobbler (some services can be found online as well).
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
Cliff Atwell, B.S., D.C.