Low back pain is highly prevalent in society today. Most studies suggest that about 80% of the population will experience low back pain at some time in their lives. For some, it is a few days of being careful how we move. For far too large a percentage of others, this pain passes into chronicity. So what creates the different outcomes?
Natural Pain Relief
ARE STEROIDS BAD FOR MY BONES?
Most people are aware that long term use of steroids is bad for the bones and can lead to osteoporosis. But what about short term use? What about use for a year? A day?
Steroids are used to control inflammation. Our body produces its own cortisol (as opposed to the synthetic cortisone), but this is under very tight regulation with feedback loops. Of course, with poor lifestyle changes and chronic stress this balance can get disrupted and create dysfunction.
This particular study gives us a better idea of just how little it can take to begin to destroy our bones with the use of steroids to control inflammation. Long term use of steroids is typical in many conditions such as lupus and rheumatoid arthritis. Short term use is also used far too common in musculoskeletal complaints like shoulder, neck and low back pain.
It is established the the risk for osteonecrosis in long term (>1 year) use of steroids increased the risk an incredibly massive 212,200 times (OR 212.2). I have personally never seen an odds ratio this high before. To put this in some degree of perspective, one would have to smoke maybe 20 packs of cigarettes through a hole directly in the trachea for 100 years to increase your risk this much for lung cancer.
While this study focused on the use of steroids for lupus and RA, we can begin to see how short term use of steroids for musculoskeletal conditions are largely inappropriate.
The risk of osteonecrosis was quite striking and most often affected the hip. Researchers identified some very interesting trends. The first set of items they looked at was how long ago someone who experienced bone death was exposed to steroids. Oral, injected or IV did not appear to be different. In other words, you took a course of steroids for low back pain last week—how much did this affect you vs taking a course 3 years earlier….
- Use ONE day to 90 days ago risk was increased 580%
- ½ year to 1 year increased 890%
- More than 2 years earlier 430%
Can we begin to see that routine use of steroids (for conditions that would very likely respond well to chiropractic care) can increase the risk for serious long term consequence even years later?
So, while my opinion as a chiropractor is clearly biased, the decision to use a non-drug effective alternative to any musculoskeletal complaint continues to be strongly supported by the medical literature.
THINK YOU SHOULD WAIT AND SEE IF YOUR LOW BACK PAIN GOES AWAY?
Low back pain will affect some 80% of us in our lifetimes. For some, it the first episode ever. For others, it’s the second or third or fourth episode in as many years. Others seem to “throw out” their back just by sneezing. So what do most people do when they experience an episode of low back pain?
They wait and think it will get better.
I always envision an episode of Family Feud where Richard Dawson poses the question…”Name something commonly heard in a chiropractor’s office.” The first family would throw out, “I thought it would go away!!” and this flips over as the number one answer on the board and the crowd goes wild..
I used to say that my opinion that waiting it out was a bad idea was biased. Not so much so anymore. Multiple studies have come out finding that delays in seeking treatment can produce worse outcomes and a greater likelihood to progress to chronic pain. And given that chiropractors are, based on the evidence, the best first choice for care of musculoskeletal complaints, you should, of course, see a chiropractor NOW.
This particular article looks at what happens if someone with symptoms stemming from a lumbar disc herniation wait to seek care. Those that waited at least 6 months had a worse outcome than those that did not, confirming what we already knew…
EFFECT OF BUPIVACAINE ON INTERVERTEBRAL DISC CELL VIABILITY
EPIDURALS DESTROY THE DISCS? There’s some convincing evidence that have epidurals (for neck or low back pain) actually increases the chance that someone will have surgery. At first thought this sounds strange, and I have usually considered the association as one more of a trajectory of treatment–taking the more invasive path (that actually begins with MRI or CT far, far too early in the game) leads ultimately down to surgery. Strong data supports a huge cost savings if a chiropractor is the first point of entry for any musculoskeletal complaint, and we’re just not prone to ordering advanced imaging, epidurals, medication or surgery until it’s absolutely needed.
This study, while not done in humans, finds that the anesthetic commonly used in epidurals (and this DOES include the ones used for giving birth) actually causes the cells of the disc to die off. Generally not a desirable outcome. The answer? Always, always see a chiropractor first for any type of musculoskeletal complaint.
IS THE ARTHRITIS IN MY SPINE THE CAUSE OF MY PAIN?
IS THE ARTHRITIS IN MY SPINE ON MY MRI THE CAUSE OF MY PAIN? This article finds little correlation between arthritis on CT scan and pain. The concept of arthritis causing pain is something I deal with every day. Having a patient tell me “my doctor said I have arthritis” is common.
The problem is it that just because you have arthritis (spinal or otherwise), it does NOT mean you have to have pain or that the arthritis is even causing the pain. Can’t tell you how many times an “arthritic knee” was completely pain free in 3-4 visits. Did the arthritis get fixed? Of course not–it just wasn’t what was causing the pain in the first place. Before anyone has anything done because they “have arthritis” I would strongly recommend they find someone adept at soft tissue manipulation work on the problem spot. You might be surprised at the results.
LUMBAR DISC PROBLEMS? YOU MAY HAVE THIS…
Nothing in the body happens in a vacuum. Every single systems interacts with every other system. People at increased risk for heart disease are at increased risk of colon cancer. Diabetes increases the risk for Alzheimers and Parkinsons. So what about disc degeneration / arthritis of the lumbar spine?
First of all, we need to understand what contributes to disc degeneration in the lumbar spine. Several factors have been identified. Genetics may play a role, but it’s likely to be the smaller role.
There are some strong associations between cardiovascular disease and disc degeneration. The inside 2/3 of the disc does not have its own blood supply, but rather gets its nutrients from small blood vessels in the bone of the vertebral body above and below. These small blood vessels may very likely be what links heart disease and disc degeneration.
Early atherosclerosis (plaquing of the arteries) due to cardiovascular disease, will reduce blood flow through these small blood vessels and thereby reduce nutrient delivery to the inside of the discs. In addition, the outer 1/3, which does have its own direct blood supply, will also be affected by this plaquing.
Less nutrients means less ability to heal which means a greater likelihood of breaking down faster. This leads to early onset disc degeneration. So what does this really mean?
It means that disc degeneration, because it is occuring throughout the body, is not going to be limited to only one area of the spine. Supporting this, this study finds links between lumbar disc degeneration and cervical disc degeneration. As a matter of fact, in those patients who had lumbar disc degeneration, almost every one (98%) had cervical disc degeneration.
However, in the control group who had neither low back or neck pain, 88.5% had disc degeneration in the cervical spine. Wow! That’s a really high number. Keep in mind these people were pain free, and yet the vast majority had “problems” found on MRI. Consider this next time your primary care doctor orders an MRI and refers you for a surgical consult…
DID YOU GET THIS AFTER A WHIPLASH?
As a chiropractor, I obviously have seen many whiplash patients. And sooner is always better. I’ve found that the sooner I see a patient after the trauma (even the same day of the accident) that better the outcome. But not everyone seeks care after an accident.
There are multiple reasons why not seeing a chiropractor after trauma is a bad idea. The obviously one is that the damage from the trauma needs to be controlled and then the healing process needs to be guided. There are clearly long term problems that occur following improperly treated whiplash injuries. These include:
- Trigger points in the muscles of the neck
- Fatty deposits in the muscles of the neck
- Chronic neck pain that can last for years
Even if you do not have more than some minor stiffness after the accident, it is still wise to get an evaluation. This does not mean that you need extensive care, but a few visits can go a long way towards fixing any imbalance that occurred as a result of the trauma.
If someone does not seek an evaluation after trauma, it is possible that problems will creep up months later, again because of an imbalance created. This particular study lends support to this idea.
The jaw (temporomandibular joint, or TMJ) generally does not get directly injured in a car accident. However, it is very susceptible to imbalance between the muscles in the back of the neck (injured during whiplash) and the muscles that open the jaw.
24% of the patients in this small study developed jaw pain some time after the accident. Even more interesting, those who experienced low-speed accidents were more likely to suffer jaw pain. Is this because they chose NOT to get care immediately after the trauma??
WHAT HAPPENED AFTER YOUR MRI?
It doesn’t happen all the time, but it is not uncommon for a patient to call our office to cancel an appointment because they went to their PCP, the PCP ordered an MRI and now they have to see a specialist. Sound reasonable?
There are multiple layers of “wrong” in this scenario. First and foremost is that, in most situations, we have already identified whether a disc bulge / sciatica was present based on talking to the patient and our exam finding. At this point, without any type of red flags, it is never, ever recommended to order an MRI this early in the treatment. Happens all the time, but apparently, those ordering the MRI are not reading the studies.
Not only is this a tremendous waste of resources, but it is well documented that this starts the patient on a MRI to epidural to surgery pathway, despite evidence that this is not the best pathway for the patient. It is also far too common for the PCP to steer the patient away from chiropractic care to a specialist–when chiropractic care is exactly what they need.
So what about the epidural’s effectiveness in the case of chronic (>12 weeks) radiculopathy (leg pain)? This particular study finds it worse than worthless—actually giving a small injection of saline was massively more beneficial than the steroid injection (Oswestry change after 52 wks– saline 14.3 points improvement, epidural 1.9 points worse). So basically, the epidural clearly made the patient worse as time went on.
The bottom line is that chiropractic care, for all musculoskeletal complaints, is the best place to go to get the best outcomes for your pain. Let the chiropractor decide if an MRI and epidural is appropriate.