LifeCare Chiropractic

The Best Chiropractic Care in Mesa, Arizona

Disc Problems

Degenerative Disc Disease in the Back; Mesa Chiropractic Shines YET Again

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The preconceptions surrounding chiropractic care are legendary. For those who have seen a Mesa chiropractor, the advantages are usually clear.

For those who have never been to a chiropractor in Mesa, however, there are a long list of fears and incorrect ideas.  Unfortunately, many physicians outside of chiropractic share the same fears and misconceptions.  If these erroneous thoughts were non-existent, I personally think the musculoskeletal health of this country (and globally) would be in a much better state.

One of these misconceptions deals with chiropractic care being useful only for acute, non-specific low back pain.  Neck pain, disc injuries, arthritis of the spine, knee pain, shoulder pain, carpal tunnel—none of these are on the list of generally acceptable conditions that chiropractic can treat.  However, these conditions and more are seen quite commonly in our office.

There is research on the effectiveness of Mesa chiropractic care for some of these conditions but it is usually limited to manipulation only, yet many musculoskeletal conditions have a pretty significant soft tissue component to can’t be addressed with joint manipulation.

So anytime I see a study that shows a positive effect with manipulation alone, I can feel confident that, which the addition of competent soft tissue work, the outcomes in real life (outside of a research study) are going to be pretty darn good.

All of this leads me to this particular study.  In it, researchers looked at 40 men who had been diagnosed with degenerative lumbar disease at L5-S1.  These men were divided into an adjustment group, who only received a single adjustment (L5-S1 “pull move”) or into a control group with no treatment.  They were then evaluated for various outcomes, including:

  • Participants’ height using a stadiometer (that height bar thingee on your doctor’s scale)
  • Perceived low back pain (measured using a a10 point VAS scale)
  • Neural mechanosensitivity (how much tension was in the nerves using a passive straight-leg raise
  • The amount of spinal mobility in flexion (measured using the finger-to-floor distance test)

If you understand chiropractic care, you will not be surprised to find that all of these measurements were improved in the chiropractic treatment group over the placebo group.

It would be easy for detractors to say that this was a single treatment that really doesn’t mean anything long-term.  The easy response to this would be to ask what medical treatment for degenerative disc disease is anything other them temporary?  And how many of these have a very small list of only minor side effects?

The answer is, of course, none of them.  Even if chiropractic care provided no long-term benefit in this situation, if you suffer from chronic low back pain, even a single days’ relief is valuable.  And none of this looks into whether or not a course of chiropractic care can have more long-lasting effects, but I can tell you from personal experience that the results can be very strong.

So if this fits you and you have not been to a chiropractor in Mesa, what are you waiting for?

 

Cervical Disc Bulge: Do I Need Surgery?

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Disc bulge in neck
Disc bulges usually do not need surgery

Now, before I state that our office does very well with disc bulges in the neck, I need to preface this with the fact that we’ve had 2 patients in the past 6 months end up in surgery.

That being said, the vast majority of patients who have cervical disc bulges accompanied by pain in the arm due to that disc bulge that are seen in our office recover nicely. Because back and leg pain are more widely publicized, there is more knowledge about sciatica from back pain; patients frequently come in stating that his or her “Atica” or “schizophrenia” is flared up. Most of these cases are not actually true sciatica (despite what he or she has been told) but are either local pain (no leg pain) or a referred pain from the hip or sacroiliac joint.

Pain in the arm originating from the neck is also very common, but less patients who walk through the door seem to be aware of this relationship. The typical patterns of disc pain in the arm or leg follow a very typical pattern called dermatomes. The problem is that there are many other things that also cause pain into the arm such as the rotator cuff, problems in the forearm such as carpal tunnel and problems stemming from the muscles around the neck such as the anterior scalene or pec minor.

Because there are so many causes of pain into the arm, it can be challenging to nail down exactly what may be causing your problem. For me, sometimes the answer isn’t clear on the first visit or two, but rather, takes some time to clarify exactly what’s causing the pain. Disc bulges in the neck causing pain in the arm can look an awful lot like a rotator cuff referral into the arm. If I work on the rotator cuff for a visit or two and nothing changes, we shift gears towards a treatment of a disc bulge.

Treatment of a cervical disc bulge in our office involves soft tissue work (Graston, stretching, fascial work), chiropractic adjusting and traction. I’m a big fan of home traction devices as well that can allow you to treat the disc bulge several times a day (we recommend this one from Amazon: Instapark® Cervical Neck Traction).

With this approach, the vast majority of patients respond well. This particular study supports this position. In it, chiropractic researchers looked at a group of studies to get a better idea of how long it takes someone to recover from a cervical disc herniation. Here’s what they found:

  • On the down side, they found that complete recovery could take as long as 24-36 months.
  • Luckily, patients were already noting substantial improvements within the first 4-6 months.
  • Overall 83% of patients resolved completely.
  • Patients with a workers’ compensation claim appeared to have a poorer prognosis.

Before you start getting depressed about the 4-6 months timeframe, in our office, if we are going to be able to help a disc pain patient, improvement starts within a few visits and usually progresses forward from there. The use of the traction device helps.

As for the worker’s compensation portion of the equation, I wonder if the poorer prognosis has to do with less of these patients making it into chiropractic offices in a timely matter. Many primary care doctors don’t consider chiropractic for disc problems and will usually use medications and pain injections first.

Radio Frequency Ablation Dangers – 4 Things to Know

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“They’re going to burn out the nerves in my neck.”  Sounds pretty permanent, but fortunately, not accurate.

Radiofrequency ablation or neurotomy, aka RFA, is a procedure done in a pain management or anesthesiologist’s office.  RFA is the next step after a series of epidural steroid spinal injections have failed to provide lasting relief.  Usually, a nerve block procedure is done first as a test to see if burning out the nerve is going to be done on the correct level or area.

As I mentioned, this does not “burn out” the nerve.  Rather, it is a procedure that uses a high frequency electrical current at a very specific temperature to destroy the myelin sheath that surrounds the nerve, while not damaging the nerve itself.  For low back pain (not sacroiliac pain) caused by the facet joints, the nerve that is cauterised is the medial branch nerve that provides feedback between the joint and the brain.  If there is a problem with this facet that is creating inflammation, it is likely that there is a constant message up to the brain that you perceive as pain.  Burning off the myelin sheath cuts off communication between that facet and the pain centers in the brain.

Sounds like a great idea and sometimes, it is one of the few options left to patients.  While I don’t have any numbers to back me up, I would not be surprised if a large chunk of patients referred for RFA have never seen a chiropractor.

So what’s the problem if it works?  Even if it is just temporary (the myelin sheath ultimately grows back and the communication between the facet and brain is restored, usually taking anywhere from 3-12 months)?  The problem, like all medical procedures, is that there are dangerous side effects.  But before we get into the gist of this blog post, I need to highlight some problems that occur when the nervous system is cut off from a joint.

Charcot joint (aka neuropathic arthropathy) occurs when damage is done to the nerves feeding a joint.  This can be from diabetes, leprosy, syphilis or any other disease process that destroys the nerves.  Ultimately, the joint breaks down and severe joint damage occurs.  While the exact mechanism is still not understood, part of this process is believed to occur by dysregulation of the autonomic nervous system that leads to an increased blood flow to the denervated joint.  This increased blood flow results in weakening of the bones surrounding the joint and breakdown of the joint.

In addition, it is possible that the lack of feedback from the joint due to the nerve damage leads to further damage and destruction of the joint.

Back to this particular study.  In it, researchers looked at the long-term effects of radiofrequency ablation on the disc, joints and muscles surrounding the joint (specifically the multifidus).  Here’s the details:

  1. 27 patients were identified that had before and after MRIs done.
  2. Spinal levels not treated with RFA were used for comparison.
  3. The disc in the area of the radiofrequency ablation had 342% more degeneration (14.9% versus 4.6%).
  4. Luckily, there was no difference in the multifidus cross-sectional area or rates of deterioration in the facet joints.

The greatly increased disc breakdown is not a good thing.  There is a chance that all of the damage was not caused by the RFA since we already know that epidural steroid spinal injections also increase the degeneration that occurs within the disc  and it is highly likely that patients had epidurals before they got to the point of needing a RFA.

Either way, this information once again supports the idea that chiropractic care should, unequivocally be at the front end of care for musculoskeletal complaints and especially spinal complaints.  This does not ensure that epidurals and radiofrequency ablations will not happen, but it darn well makes sure it’s only used as a last resort.  And a last resort is where it should sit.

 

Muscloskeletal Pain? Primary Care Docs Not Giving Good Advice

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Sciatica.  Knee osteoarthritis symptoms.  While these two conditions seem a world apart, there is something they have in common:  Bad advice.

Both of these conditions have solid research on things that you should and should not be doing to help you recover.  The “should” category involves exercise and moving around.  Almost always with musculoskeletal pain, moving around is better and staying sedentary is a very bad idea.  While my opinion is clearly biased on this one, the acceptable medication approach to most musculoskeletal complaints involves the use of NSAIDs like ibuprofen.  Strong pain medication like opioids (Vicodin, Percocet) should not be used, especially initially, and fall into the “should not” category.

In the “should not” category is also imaging.  While plain X-rays may be appropriate to evaluate for osteoarthritis symptoms, advanced imaging like MRI and CT scan should not be ordered unless certain red flags are present.

All of this is well supported by the medical research over the past 10 years or so.  But one of my continued frustrations with all branches of medicine is just how rare it is for doctors to actually crack open medical journals.  The research itself suggests that doctors are, in general, about 19 years behind the medical literature.  That means that this particular article, looking at just how well primary care doctors understand the current recommendations for sciatica and osteoarthritis symptoms, won’t grace the typical doctor’s eyes for two more decades.

Basically, they won’t know that they don’t know until around 2033.

Just in case you think I’m being a little too facetious, let’s look at what researchers found in the study:

  1. Despite the clear benefit, less than 1/3 of physicians would give exercise advice (30.2% for osteoarthritis, 32.8% for sciatica).
  2. Overall, though, at least newer docs were more likely to give advice on exercise (39.6% of newer physicians versus 26.0% of older docs for sciatica / 20.8% for osteoarthritis).
  3. Newer physicians were less likely to order tests like CBC or CMP (9.4% vs 21.9%) or a urinalysis (4.2% vs 16.7%).
  4. For osteoarthritis, X-rays were more often ordered by newer physicians (85.4% vs 69.8%).

Overall, these numbers reflect poorly on the typical primary care doctors’ ability to handle common musculoskeletal complaints.  For my entire chiropractic practice life I have been confronted with patients and people in the community that ask whether they should see his or her primary care doctor or a chiropractor first.  The evidence is very clear–seeing a chiropractic physician first is the best option that will be more likely to lead you down a path with the best and most efficient outcomes.

But clearly I’m biased.

Steroid Injection Epidurals For Spinal Stenosis–Boon or Bane?

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Epidurals are handed out like candy in this country. We assume that, much like surgery and medications, that there are hordes of research studies documenting the effectiveness of this intervention.

Regular readers of the Rantings and any chiropractor out there will tell you this couldn’t be further from the truth.

Yet this doesn’t seem to stop primary care doctors from referring patients out for epidurals long before they would consider a referral to a chiropractor (data from a major insurance company in the US notes that a measly 6.6% of non-surgical spine episodes that do not begin with a chiropractor will ever be referred to one for care, and even then this is VERY late in the episode).

Possibly this lack of referral is because primary care doctors don’t think there is research supporting chiropractic care (not true).  But this doesn’t seem to halt the referral to pain management centers to perform expensive, invasive procedures with evidence actually against their use that carries a much higher risk than manipulation.

Just seems strange to me.

That’s not to say that I don’t believe epidurals have a place in medicine, because I do. I have referred non-responsive patients out for them in the past, but they are few and far between and always for leg pain that is consistent with a disc herniation.  This scenario is a far cry from what is happening in the arena of low back pain in mainstream medicine today.

I can’t tell you how many times I’ve had patients sent for epidurals for isolated low back pain with no leg pain involvement.  Ugh!!

But what about leg pain associated with spinal stenosis-a condition where advanced arthritis of the spine begins to choke off the room for the nerves going into the leg?

Just recently I had just such a case.  After the 2nd visit using Flexion-Distraction he had absolutely no response to treatment.  So on the 3rd visit I really ramped up the agressiveness of the treatment with instructions to only return for additional treatment if he noted improvement after this visit.

I was fully expecting to have a discussion about a referral to pain management for this patient.  Luckily, that last treatment broke through the barrier and he had a pretty substantial improvement.  His outcome is going to be good.

But what if it wasn’t?  What if the 3rd visit didn’t help?  I’ve had stenosis patients in the past who did not have a strong response.  They are few, but they happen.  An epidural would seem to me to be a better option than referring that patient out for a surgical consult.

At least that’s what I thought until I came across this particular article.

The premise of this study was that the use of an epidural spinal injection for spinal stenosis patients would lower the need for, or at least delay, surgery.  Boy, were they surprised.

In looking at a group of patients who had an epidural spinal injection in the first 3 months of the trial versus those who did not, there were some enlightening findings:

  1. Those who received the epidurals had a much higher preference for avoiding surgery (62% versus 33%).
  2. In those who got the epidural but ultimately ended up in surgery there was a 26-minute increase in operative time and an increased length of stay by 0.9 days.
  3. Over 4 years, there was 34% less improvement in overall quality of life (measured using the 36-Item Short Form Health Survey (SF-36) Physical Function) among the epidural patients that ended up having surgery.
  4. There was less improvement in the epidural patients (56% less on Body Pain and 64% Physical Function).
  5. Of the patients who were initially in the non-surgery group, those who had an epidural were 45% more likely to switch to the surgical group.
  6. On the only positive note, the patients who were originally in the surgery group who got the epidurals were 1/3 less likely to actually follow through with surgery.

Wow!  Talk about nullifying a hypothesis!

I think that we, as a society, need to really rethink what steroids might be doing to our ability to heal, and accept the fact that the use of steroids applied directly to sensitive spinal structures may very well be doing far more harm than good.

Just my two cents (and a lot of medical research, too…).

Lumbar Spine Fusion: Are You a Good Match?

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There is a time and place for surgery.  I think few would argue this point.  But I have seen patients have imaging, injections and surgery for cases that never should’ve been considered a surgical case.

Of course, whether or not they are a surgical case is merely my personal opinion.  Since I’m NOT a surgeon, and I’m JUST a chiropractor, I could not even begin to know which cases of low back pain are or are not surgical cases.  Given something as invasive, dangerous and permanent as spinal surgery, surgeons are the ones that can do the tests to definitively know whether or not a patient’s low back pain is surgical or not.

Spinal fusion involves slicing into the tissues surrounding the spinal column and then using either a special cement or titanium hardware to lock two (or more) spinal segments together so that they no longer move.  The costs are staggering and the recovery, from the patient’s standpoint, is a major deal.

Again, good thing the surgeons can tell when someone needs surgery or not by doing the correct tests.

Ok.  So you know where this is going.  This particular study looked at just how accurate commonly used tests were at determining whether or not someone was going to have a good outcome from a spinal fusion for low back pain.  Specifically, researchers looked across 10 studies to see whether these tests were actually useful:

  • Findings on MRI
  • Provocative discography (an irritant is injected into the disc; if it hurts, that must be the problem)
  • Facet joint blocks (the spinal joints are injected with an anesthetic; if it helps, that must be the problem)
  • Orthosis immobilization (using a brace to immobilize the lumbar spine; if it helps, the area needs to be fused)
  • Temporary external fixation (a temporary metallic brace is screwed into parts of your vertebrae)

So what did the authors say after looking at all these tools to determine is lumbar spinal fusion was going to have a good outcome?

No subset of patients with chronic LBP could be identified for whom spinal fusion is a predictable and effective treatment. Best evidence does not support the use of current tests for patient selection in clinical practice.

In other words, it’s a crap shoot.

The bottom line is that, if surgery has been recommended to fuse your lumbar spine and the surgeon looks you in the eye and says he or she is confident this is the right thing to do, it’s time to find another one.  Before you go on to surgery, have you REALLY tried everything?  Has chiropractic been used?  Soft tissue treatments like Graston, ART or Fascial Manipulation?  Yoga?  Massage?  Rehab?

If you can’t answer yes to ALL of the above, it’s not time for surgery.  Surgery should be the absolute last possible option that you should consider because no one can predict the outcome for your situation.

 

Slipped Disc in Back: Common Sciatic Nerve Treatment Falls Short

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MRI finds a slipped disc in back. Options are short, but you decide on a common sciatic nerve treatment from your doctor’s suggestion. But what’s the best option?

The task of deciding what options are the best seems daunting. Medications, injections, chiropractic (my personal favorite), acupuncture, massage, physical therapy and probably 10 others I’m forgetting.

But before you decide on a treatment, we need to back up a little. The conversation needs to start with where you got your diagnosis. The diagnosis of a disc problem (slipped disc, disc bulge, disc herniation – the actual description is quite technical, but you get the idea) can be make quite accurately in a competent physician’s office. Rarely is an MRI needed to diagnose a disc problem, and the guidelines clearly state, that in the absence of red flags, any imaging needs to wait until 4 weeks of conservative treatment. Despite this mainstream medicine seems to want to order MRIs and CT scans at the first sign of back problems.

This is were the problems begin. Numerous studies have confirmed that early MRIs are a bad thing, driving expensive, dangerous and unneeded treatments. But let’s say you made the mistake of not going to a chiropractor first for your back pain and you did get an MRI or CT scan. And this MRI or CT shows that you have some type of problem with the intervertebral discs of your lumbar spine.

Here comes the big question. Do you have leg pain or not? And is this leg pain scleratogenous, radicular or radiating? I don’t really expect you to answer that question, but hopefully you can begin to see that just because your back pain is accompanied by leg pain this does NOT mean that you have sciatica. I can’t tell you how many times I’ve seen patients with leg pain that, after some targeted soft tissue work on his or her low back and glut region (gluteus maximus, posterior hip, rump, derriere–you get the idea), the leg pain gets better or is gone.  There is no way a slipped disc in back would respond that fast.

Sciatica refers to radicular pain that comes from chemical or pressure (from a disc) directly on the sciatic nerve. For those of you unsure of where the sciatic nerve goes, I’ll clarify. It goes into the leg. Despite this, I have seen patients spend tens of thousands of dollars for epidural injections for low back pain that doesn’t involve pain in the leg. I’m not sure there’s ever been an indication to use epidural injections in the lumbar spine for treatment of local back pain (without leg pain). It may be done all the time, but that doesn’t make it right.

Overall, this means that you need to see someone who understands all the nuances of back pain and leg pain. (hint, hint….a chiropractor). Anything short of that and you may get sent in the wrong direction.

Back to this particular article that looked at the effectiveness of epidural steroid injection as a common sciatic nerve treatment.

I have personally referred a small handful of patients out for epidural steroid injections over the years, but they are few and far between. I have never considered spinal injections as a stand alone therapy. At the most, they allow a small window of pain relief, where other options have failed, where other therapies can be used more aggressively.

So what happens if an epidural is the only therapy used? Basically, confirming other studies, these researchers found that they suck. Here are the specifics:

  • Researchers looked at 25 different studies.
  • Epidural corticosteroid injections improved leg pain 6.2 points (out of 100).
  • This was only noted in the short term (2 wks to 3 months).
  • Beyond 3 months, the benefits were even smaller–pretty much non-existent.

So basically, an epidural injection for sciatic pain is very expensive (I’ve seen bills as high as $5,000 per shot) and really does nothing but provide a small amount of pain relief for a short period of time. Worse, it may accelerate destruction of the disc and lead you to surgery. Of course, none of this takes into account the close to 400 cases of fungal meningitis on the East Coast from contaminated vials of the steroid used in this procedure, with almost 30 deaths so far.

Where do I sign up?

CHIROPRACTIC SERVICES PROVIDES RELIEF TO BACK SURGERY AND DISC PROBLEMS – (11-03-03)

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“Failed back surgery syndrome”

This one obviously hits home. Statistics show that 5-10% of patients undergoing back surgery for disc problems experience no relief. While these odds may seem pretty good, the number of back surgeries done in a year make the total number quite high. Roughly 10% of the population utilizes chiropractic services; it is entirely possible, based only on my personal experiences, that if utilization increased the number of patients going to surgery would drop dramatically. While chiropractic care is not always 100% affected, you can bet that, at the very worst, you will be in the same condition you presented with. You can’t say that with surgical procedures.

bmj.com Talbot 327 (7421): 985.

Read entire article here