LifeCare Chiropractic

The Best Chiropractic Care in Mesa, Arizona

Low Back Pain

Back, neck, and shoulder pain in Finnish adolescents – (10-10-02)

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Back, neck, and shoulder pain in Finnish adolescents

From a business standpoint, this ain’t such bad news. Unfortunately, there is currently no shortage of adults with musculoskeletal pain and we don’t need to add children to this already-too-long list. Children experiencing pain at this age does not bode well for future musculoskeletal health. If these kids do not get proper care now(i.e. chiropractic….), future episodes will generally increase in severity. It is possible that this increase is from a combination of factors, including decreased physical activities, heavier backpacks in school (I know this is a problem in the US, not sure if the same problem exists in Finland) and a more pro-inflammatory diet with more animal products and less fresh fruits and veggies.

bmj.com Abstracts: Hakala et al. 325 (7367): 743 –

Read entire article here

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…).

Had Spinal Injections? You’re Twice As Likely to Accept This

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As I have written in past articles that there is a time and place for surgical intervention for low back pain.  The same is true for interventional pain management like epidural spinal injections.

I currently have an older male patient who has a pretty textbook case of lateral recess stenosis (for those of you less familiar with medical terminology, it means that arthritis in his spine has begun to choke off the nerves of his lower back as they exit the spine, leading to pain down the leg, especially with standing or walking).  Generally, our office does exceedingly well with these types of patients using a technique called Flexion Distraction.  But there are a very small percentage that do not respond.

This recent patient, after 3 treatments, is fitting into this category.  He has not noted any difference despite the treatment we have done.  The likelihood of him responding goes down precipitously from here.  On the last visit, we discussed the potential for epidural spinal injections if he does not respond within one more visit.  In our office, this patient is a clear candidate for spinal injections.

However, this treatment pathway is not altogether typical.  I have seen patients treated with interventional pain management (trigger point injections, epidural spinal injections, etc..) that wer not good candidates and did not respond well.

But here’s where things get interesting.

I remember a meeting several years back with one of the nation’s larger health insurance carrier.  On a conference call, one of the big wigs mentioned that merely having an MRI or an epidural spinal injection would increase that patient’s likelihood of having spinal surgery.

At first thought, this seemed crazy.  I mean..how could merely having an MRI increase your risk of having surgery??  Or even an epidural spinal injection?

Regardless of how much it does or does not make sense, the relationship is clear and has been documented in multiple studies.  Personally, I have always felt that, once patients are sent to an MRI that they shouldn’t have had, they are told that something tangible is wrong with his or her back.  Pay no attention to whether or not that disc bulge or arthritis is causing your pain–there is something wrong!

This starts the patient on a trajectory based on a potentially false set of information.  In today’s version of mainstream medicine, far too often this is the only trajectory the patient will ever experience.  If someone is convinced that there is an actual problem found on an MRI that needs to get fixed, the thought of an epidural or surgery naturally follows.

As it turns out, I may not have been too far off.  This particular study helps give some additional insight into the relationship between epidural spinal injections and spinal surgery.

Patients were asked about his or her likelihood to undergo spinal fusion surgery when faced with 3 potential complications (nerve damage, wound infection, and nonunion of the fusion) and educated on the likelihood of experiencing symptom relief.  For each scenario, the patient indicated whether he or she would or would not undergo spinal fusion.

Here’s what they found:

  1. Patients were more likely to accept spinal fusion with lower risks and better outcomes (no big shocker here…).
  2. Greater low back pain intensity made patients more accepting of higher surgical complication risks.
  3. Greater leg pain intensity had a weak correlation to opting for spinal fusion.
  4. One of the strongest factors of undergoing surgery despite a higher risk of complications was a history of spinal injections (almost twice as likely to opt for surgery) (Tweet this).

To sum it up, if someone had a spinal injection at some point, he or she was twice as likely to still say yes to a surgical fusion despite a higher risk of complications.  This is a pretty darn strong difference.  Pain severity, age, education status, duration of pain symptoms….all of this was less important then whether or not someone had spinal injections.

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.

 

Low Back Pain: Not Just for Adults Anymore – (08-30-02)

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Low Back Pain: Not Just for Adults Anymore

Although back pain is usually thought of as an “adult” problem (research shows that up to 80 percent of all adults worldwide will suffer low back pain at least once in their lifetime) new evidence suggests that back pain is becoming an increasing problem for children and teenagers, and that a variety of factors can lead to this condition.

Researchers questioned more than 10,000 Israeli schoolchildren in 1st through 6th grade regarding their average weight, average weight of backpacks, if there were on-campus facilities to store backpacks, the height of chairs and desks in relation to student height, seating arrangements, and physical activity during recess.

Results: Between 30 percent and 54 percent of the students carried bags containing 15 percent or more of their body weight; almost 15 percent of the 1st graders and 20 percent of 6th graders sat in chairs of “inappropriate” height; in 74 percent of the classes, students sat with their sides facing the instructor and in another 35 percent, students sat with their backs to the teacher; 30 percent of the schools did not have storage facilities for backpacks; in 48 percent of the schools, there was no organized play activity during recess and in another 6 percent there was no provision for any type of physical activity during recess.

Parents, your children may be at risk of developing low back pain. Fortunately, you can take several steps to maintain your child’s health: Monitor your child’s backpack for weight; talk to the school about repositioning desks and physical activity; and of course, have your child examined regularly by a doctor of chiropractic – it could prevent years of unwanted back pain.

To learn more about back pain and the chiropractic approach to its prevention click here.

Reference: Limon S, Valinsky LJ, Ben-Shalom Y. Children at risk. Risk factors for low back pain in the elementary school environment. Spine, March 15, 2004;29(6):697-702.

Steroid Injections Result in Only Limited Short-Term Benefits for Sciatica – (11-21-02)

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Steroid Injections Result in Only Limited Short-Term Benefits for Sciatica

Considering that I see sciatica on a daily basis in my office, this study does not surprise me. What does surprise me is how people still does consider chiropractic when considering options for sciatic pain. I’m proud to say that I have not had a single patient that stuck with me for sciatic pain due to a disc herniation go to surgery. Some of the case were tough, but all resolved without surgery. Also, I have occasionally sent patients for epidurals, but not as the only therapy. That may have been the problem with this study. As one tool to lower the level of inflammation, it can allow other therapies to be more effective. The same goes for shoulders. In now way, shape or form do drugs or injections fix whatever was wrong with the problem.

ACR 66th annual meeting: Abstract 530. Presented Oct. 26, 2002.

In patients with sciatica, epidural injections of corticosteroids appear to produce only limited relief and no sustained benefit, according to findings from the largest randomized controlled trial of its kind.Nigel K. Arden, MD, a senior lecturer in rheumatology at the University of Southampton, U.K., and colleagues presented their research here Saturday at the American College of Rheumatology (ACR) 66th Annual Scientific Meeting. According to Dr. Arden, the procedure is fairly common. “In the U.K., for every million population that comes into the hospital, we are doing 800 epidurals,” he said. To evaluate the efficacy of corticosteroid epidurals, the researchers recruited 228 patients with clinical evidence of unilateral sciatica from four hospitals. At baseline, patients from two of the hospitals underwent magnetic resonance imaging (MRI) of the lumbar spine. Patients were stratified based on whether they had acute or chronic sciatica and were then randomized to receive either three weekly lumbar epidural injections of triamcinolone acetonide 80 mg and bupivacaine or three injections of saline into the interspinous ligament.Patients were assessed at 0, 3, and 12 weeks. Both groups improved at 3 weeks, but the active group had a slightly greater but nonsignificant improvement compared with the placebo group (Oswestry score, 33.5 vs. 38.9; P=.053). At three weeks, 60.8% of the participants in the active group and 39.8% of those in the placebo group reported that their sciatica had improved (P=.03). But at 6 weeks and 12 weeks, the differences were no longer significant (P=0.5 and 0.7, respectively). In addition, the researchers also performed several a priori subgroup analyses to explore predictors of response, such as duration and severity of sciatica at study entry, presence of a significant MRI lesion, and the presence of neurological dysfunction; however, none of these predicted a response.”This study was meant to be the definitive study,” Dr. Arden said. “We used the highest dose and most potent steroid possible,” he said. “We even powered it so that we could pick up a nonclinically significant effect,” he added.”There is no quick fix or magic injection,” says Dr. Arden. According to Dr. Arden, the answer may be to combine pain relief with physiotherapy. “Only a small amount of this condition is physical, so if the patient is also depressed, they should also see a psychologist,” he added. Dr. Arden pointed out that pain consultants tend to think these injections work whereas “rheumatologists tend to think they do not work.”Sidney Block, MD, the session moderator and a rheumatologist in private practice in Bangor, Maine, agreed. “I think it has to do with the perspective of the physician,” he said. “Orthopedists, who are not anxious to operate on a patient’s back, will frequently turn to this as a method of pain relief hoping that it will delay the need for surgery.” “Rheumatologists may also turn to this before surgery, but this study raises the question as to whether this therapy is effective,” he said.

 

Rapid MRI vs Radiographs for Patients With Low Back Pain – (06-17-03)

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Rapid MRI vs Radiographs for Patients With Low Back Pain

This study found no additional benefit to ordering MRI over standard Xrays. Interestingly, this study found that patients who had MRIs were more likely to undergo surgery. Basically, this supports what I always tell patients–just because something shows up on an MRI (i.e. disc herniation) does not mean that it is causing your current symptoms. Nothing replaces a good exam. An MRI should NOT be used to make a diagnosis, but rather to confirm what you already know or clarify a difficult case presentation.

JAMA — Abstracts: Jarvik et al. 289 (21): 2810

Read entire article here

Epidural corticosteroid injections for sciatica – (06-23-03)

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Epidural corticosteroid injections for sciatica

The epidural for low back pain is always one that hits close to home. In my own practice, I rarely see long term benefit from steroid injections. Flexion/distraction therapy is an extremely effective and safe treatment for sciatic pain. Also, I see a high number of patients that have been told they have sciatica but, clinically have no evidence of it. This may be another example of clinicians using advanced imaging like MRIs instead of using their exam findings and intuition.

Ann Rheum Dis — Abstracts: Valat et al. 62 (7): 639

Read entire article here