LifeCare Chiropractic

The Best Chiropractic Care in Mesa, Arizona

Low Back Pain

Chronic Lower Back Pain and Manipulation: Does It Really Work?

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Chronic lower back pain is a serious problem today, both in terms of cost of treatment and lost productivity. Plus, it just plain sucks if you’re the patient.

Let’s just get this out of the way right up front: My opinion on this article is going to be biased.  Not just because of the articles I read, but based on almost 15 years in practice.

Just today I had a new, 22 year old patient come into my office that has been having significant low back pain for over a year.  Prior to her flare up at that time, she had already been dealing with aching in her low back for years prior.  And yet, despite this, she had never been to a chiropractor.  Luckily, she did not wait until she was 35 and had 15 years of chronicity behind her.  Even after the first visit she noticed improvement and it is likely that, within a few visits, she’ll be back to 100%.

So why is this story so common?  I contend that chiropractic remains the red-headed stepchild of healthcare.  Quite frankly, when it comes to cost-effectveness and patient satisfaction, chiropractic care for both acute and chronic lower back pain rocks.  Just in case you don’t want to take my word for it, you can download my ebook on the research backing up natural approaches to chronic lower back pain here.

Let’s just play devil’s advocate for a second and say that there is no research to support chiropractors as the go-to physician for a back pain specialist.  And I do believe that this is much of the perception for the limited referrals to chiropractors from mainstream medicine.  Why should we, as chiropractors, be held to a higher standard?

By a higher standard, I mean that we don’t have billions of dollars of research supporting what we do.  Research that states, unequivocally, that chiropractic manipulation for musculoskeletal disorders is effective.  Of course, we do have research that supports what we do, although this is limited because of the lack of financial support our profession has for research.  No drug companies sponsoring our research.

So, the chiropractic profession (and alternative medicine in general) is expected to be backed up by hundreds of randomized placebo controlled studies documenting effectiveness.  Without these studies, other physicians are slow to make a referral to chiropractic care a first option.

Here’s the double standard.  I can say, with a relatively high degree of authority, that very little of what mainstream medicine does is supported by the same type of medical research that is expected of alternative medicine.  And this lack of strong research is despite literally billions and billions of dollars spent on research.  Did I say billions of dollars?

In almost all case, the second a physician adds a second prescription to a patient’s regimine, they are out of the realm of research and into guesswork.  And this is assuming that the original prescription was not for an off label use or actually has research suggesting that that particular drug was useless or even harmful.  I could go into lots of examples such as beta blockers, hormone replacement therapy and statin drugs, but lets just leave it as it is.

This particular study is yet another study supporting the use of manipulative therapy for chronic lower back pain relief.  While the study was small, the findings were very consistent with what most chiropractors see every single day in practice:

The was a definite and immediate reduction in pain intensity directly associated with spinal manipulation for chronic lower back pain (in this case, the diagnosis with chronic non-specific lower back pain) (Tweet this).

Of course, rarely does chiropractic care include just manipulation as the single and only treatment given.  Many of us use soft tissue manipulation (my personal favorite in my toolbox) and rehab to improve outcomes in patients.  Adding additional tools to chiropractic adjusting for the treatment of your pain should be the first thing you think of anytime something hurts.

I’d apologize for the bias inherent in the blog article, but I did fully disclose this bias in the beginning…

 

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?

TOOLS REVIEW FOR CERVICAL SPONDYLOTIC SURGERY – (05-02-02)

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Review of Surgery in Cervical Spondylotic Radiculomyelopathy

Of course, as a chiropractor, this one hits close to home and brings to mind the accusations that chiropractic is not effective. Personally, I feel that chiropractic (and natural medicine) is held to a higher standard. Ironically, these approaches are well up to the task, while traditional medical therapies typically are not. There have been numerous reviews on the effectiveness of manipulation for both neck and low back pain showing varying levels of effectiveness, and here we see a review article that finds evidence lacking for one of orthopedic surgeons main tools for neck pain.

Lippincott Williams & Wilkins – Spine –

Read entire article here

FIRMNESS OF MATTRESSES EFFECTS CHRONIC NON SPECIFIC BACK PAIN – (11-30-03)

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Effect of firmness of mattress on chronic non-specific low-back pain

This is interesting, an a question I hear frequently in my office. Unfortunately, the answer is never easy and seems to vary based on the patient. I have a patient that used to work in R&D for Simmons company, and his company found that the firmness needed is dependent upon primary tissue involvement; i.e. muscle problem or joint problem. This would explain why different patients would respond differently to different mattress firmness.

The Journal : Back Issues.

Read entire article here

REVIEWS ON ACUTE LOW BACK PAIN – (08-14-03)

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Acute low back pain: systematic review of its prognosis

As a chiropractor, it is really hard to pass up an article like this one!! I can verify the findings in this an several other studies from what I see in my office. Low back pain is not a one time episode. Rather, it is a continuim of flare ups and remissions–with all the episodes essentially being one long one. However, although there are no studies to back this up to date, I see time and time again that intervention with chiropractic care can break this cycle and prevent future flare ups in the vast majority of cases.

bmj.com Abstracts: Pengel et al. 327 (7410): 323 –

Read entire article here

Why You Need a Back Specialist for that Sore Lower Back

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You may think your 1st episode of a sore lower back will just go away on its own. Or, it got better without seeing a back specialist. But are these good approaches?

I thought I’d share a near taboo story with you as it relates to a recent experience of mine.  I’m almost ashamed to admit as a chiropractor, but I’ve never suffered from low back pain until recently.  Sure–the martial arts have left me with shoulder, knee, ankle, foot (including a random broken toe earlier this year), elbow and wrist problems as well as the occasional headache and neck stiffness.

But never an episode of low back pain.

My first one came pretty much out of the blue.  Sure, I’d had a pull over my left glut region with bending over fully and really stretching out that I’d been meaning to get worked out with some aggressive soft tissue work like Graston Technique.  And sure, most of the people I train with in ju-jitsu outweigh me by at least 50 pounds AND are more skilled than I am (not a good combination, in case you’re not able to figure that one out…at least for me).

But there was no single defining episode that kicked it off.  And this is pretty darn consistent with what patients who have had his or her first episode of low back pain will tell me.  Or at least that’s what they say if this is the first episode.

More often than not, the episode of low back back is not the first one the patient has experienced.  Far too often, this is just one of many low back pain episodes that has occurred over the years.

For seemingly ever, we have viewed low back pain as a single discreet entity, although those of us that treat low back pain understand it differently.  It is more of a continuim of occasional or frequent flare ups over the course of months, years or decades.

My personal belief is that these initial acute episodes turn into this recurring pattern because they were never properly treated in the first place.  Or not treated at all because the victim thought it would “go away on its own”.

Understanding what happens when you ignore that initial episode, I have made sure that, for my initial flare up of lower back soreness I have gotten competent soft tissue treatment and adjusting from the other chiropractors in my office.  My episode is not over, but I am confident that it began as a soft tissue problem–some tweak or thickening of my thoracolumbar fascia.

Left to heal on its own the mechanics would become altered, leading to some degree of joint dysfunction down the line.  I am making sure that it is fully addressed NOW, rather than letting it go to progress to the “typical” pattern of low back pain that so many seem to experience.

This particular study seems to support this notion.  Researchers questioned 589 people who were currently suffering from low back pain.  They asked about having prior episodes of low back pain and, if he or she had a prior episode, how did the current episode compare in regards to pain intensity, interference with leisure and work activities, duration of episodes, and pain extending further into the buttocks or legs.

Their findings were very consistent with what I see in my office:

  • In 73%; of respondents this was not the first episode of low back pain
  • 66.1% reported their first episode lasted less than 3 months long
  • 54% had experienced 10 or more episodes
  • 19.4% had more than 50 episodes.

In those with recurrences, 61.1% reported that at least one aspect of the pain was worse in recent episodes.

  • A mere 36.9% felt that this episode was better than the last
  • 20.5% were worse in all aspects noted above.
  • 8.6% were better or the same.

There was one last important factor teased out in the questions asked by the researchers.

In 3 out of 4 of the low back pain sufferers, the pain location changed during the episode.  Most commonly, the pain first spread further before retreating back towards the spine during recovery.  Again, a very common findings.

So what does this all mean?

First, as seen in other studies, early treatment may be critically important to prevent future episodes.  My personal bias would be seeing a chiropractor that specializes in soft tissue treatments combined with adjusting.

Second, at some point insurance needs to consider treatment for low back pain (as well as many, if not most, musculoskeletal complaints) as ongoing.  Currently, this is not the case.  Treatment for most musculoskeletal complaints is considered short term and NOT ongoing.  There currently is one middleman company that our office deals with that seems to think any type of ongoing treatment should not be authorized.

Great.  Authorize the diabetic to take insulin for 6 weeks or the hypertensive patient to take a beta blocker for 8 weeks (just kidding–we shouldn’t authorize the use of beta blockers for blood pressure at all!).  Or how about Lipitor just until your cholesterol drops below 200.

Did you seek care immediately after your first episode of low back pain, and, if so, from what type of provider?

MRI for Back Pain: Which Back Pain Doctor Uses the Evidence?

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Everyone wants an MRI for back pain. Society teaches us that more information is better, but which type of back pain doctor actually uses MRIs most effectively?

In interests of full disclosure…I’m a chiropractor. But, in my defense, what I’m about to say is not hearsay. The evidence of chiropractic care’s effectiveness and “correctness” continues to mount. Although at times we seem to remain at the bottom of the insurance company totem pole, I do believe that the future remains very bright for those of us that can survive the current storm of shrinking reimbursements despite high value care.

The term “high value care” is probably the best description of what we have to offer. Orthopedics is the highest cost driver for almost every insurance company. Within this, non-surgical spinal care is the biggest chunk. Costs in this category include providers (chiropractors, primary care, internists, physical therapists, neurosurgeons, orthopedic surgeons and a few others), medications, injection-type therapies (think epidurals) and imaging.

Ah yes. Imaging. MRIs. CT scans. X-rays.

Evidence be damned–we still hand out prescriptions for these like candy on Halloween.

Strong evidence links CT scans with thousands of cancer cases from radiation and yet their use in the emergency room setting has not changed.

Despite evidence against their use, 20% of primary care doctors hand out opioids for uncomplicated low back pain.

The standard recommendation for a course of 3 epidurals is not backed by evidence (but costs thousands of dollars for the series). Worse, evidence suggests it may cause more harm than saline injections.

Even early use of pain medication or anti-inflammatories can create a chronic problem out of an acute one.

Back to the imaging topic.

Ever since medicine has relied more and more on advanced imaging like CTs and MRIs, our physical exam and history taking has been getting worse and worse. In all honesty, in many cases, the evidence of involvement of a disc bulge or spinal stenosis can be determined without imaging. I know that in our office we are very conservative with ordering additional imaging.

However, patients seem to want the results from an MRI for whatever reason. Maybe it’s because they think that an MRI will give a definitive answer to what is wrong with them. (Not true–the only thing that will give an absolute answer to what is going on with your back is an autopsy, something we try to leave as the last resort)

After all, an MRI is harmless, right?

Very, very wrong.

The evidence that MRIs can create harm when ordered inappropriately is plentiful:

Clearly an MRI needs to be ordered only when appropriate. The alternative is not only a waste of money and time, but come with an increased risk of something being done that doesn’t need to be done.

This particular study looks at what happens with MRI ordering within the context of a workplace injury. Researchers looked at what factors increased the risk of an injured patient getting an MRI within the first 6 weeks (termed an early MRI). The results are pretty much exactly what I would expect:

  • 20% of the injured patients received an early MRI
  • Initial visit type with a surgeon was associated with 78% greater likelihood of an early MRI than that with a primary care physician
  • Having a chiropractor as the initial provider saw a 47% lower chance of an early MRI compared to a primary care physician

I DID clearly state in the beginning that I had a bias towards the chiropractic treatment of the injured worker, but it’s hard not to see my side of the story. Overall, getting an early MRI in the absence of certain red flags increases the risk of procedures like epidurals and surgery that may not be needed.

The bottom line is, according to this study, sending an injured worker to the chiropractor first, before a PCP or surgeon, results in a much lower rate of an inappropriate MRI being ordered which may lead to undesirable and unnecessary invasive procedures.

If you have been injured at work in the past, what type of provider did you see initially and how did that overall experience go?

Healing Yoga is Bad for Chiropractors

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Most patients are in my office because they’re locked up. Muscles, ligaments, tendons and joints just aren’t moving. Anything that stimulates movement is good.

This is why exercise and chiropractic can be so powerful for so many.  Because we take areas on a patient in pain and help them move better.  It really can be put into that simple of terms.  This is why yoga is so dangerous for a chiropractic practice.  Of course, our office still recommends yoga heavily.  After all, our main goal is to destroy our practice by having patients do everything they need to do outside of the office so that they no longer need us.  Unfortunately not likely to happen, it still remains a primary goal for every patient that enters the office.

As I mentioned, so many patients are experiencing pain because they just don’t move.  We live in a sedentary society both at work and at home.  If we exercise, many opt for a linear aerobic exercise like the elliptical, treadmill or stair-climber.  These lock us into a specific movement and really don’t fully allow our bodies to move.  Weight training is not too much different.  We isolate a muscle and work out that muscle to make it grow bigger.  Again–this does not take our bodies through full ranges of motion.

Activities like the martial arts (my personal choice), hiking (second choice), tennis and racquetball require your body to move in unrestricted patterns.  THIS is what we need to stay healthy and pain free.  So where does yoga fit in?

Perfectly.

This particular study demonstrates just how effective yoga can be at controlling pain.  Here are the details:

  1.  Researchers looked at 6 studies
  2. These included back pain, rheumatoid arthritis, headache/migraine were the most common
  3. All studies reported positive effects in favor of the yoga interventions
  4. With respect to pain, the overall improvement was 26%
  5. For pain-related disability, overall improvement was 21%

Not too shabby overall considering the safety of yoga.  In addition, none of these address the potential stress reduction that can occur with yoga as well, which would have benefits far beyond pain and disability.

So, if you are dealing with chronic pain issues, make sure you combine your visits to your chiropractor with regular yoga sessions to get the best benefits.

What type of yoga do you find the best for your body and mind?