LifeCare Chiropractic

The Best Chiropractic Care in Mesa, Arizona

Natural Pain Relief

Is Surgery Necessary for ACL Tears? The Answer Will Surprise You

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I personally had my right knee scoped when I was 18 for a torn medial meniscus.  I now have arthritis on the inside part of my knee, which I keep solidly pain free with soft tissue work and exercise.

Knowing what I know now, I never would’ve had that surgery done.  While this particular article looks at 121 young active adults with ACL tears (a more complex injury than a meniscal tear), it again raises questions about the dogma that exists on the need for surgery for many knee conditions.  Basically, delaying surgery and trying non-surgical management first (which, in this office would include aggressive soft tissue techniques like Graston as well as whole body vibration to stabilize the joint) seems to be the better option.

Here’s the specifics:

  • 62 were put in rehab and had early ACL reconstruction, with 59 assigned to rehab plus optional delayed ACL reconstruction
  • Of the 59 who initially did not have surgery, 23 (39%) underwent delayed ACL reconstruction.
  • Based on the Knee Injury and Osteoarthritis Outcome Score (KOOS, which asks about pain, symptoms, function in sports and recreation, and knee-related quality of life), there was NO difference in any of the treatment approaches.

In other words, just because you have an ACL tear does NOT mean that you have to have surgery.  It makes complete sense to go into rehab after an injury like this with the expectation that you will not need surgery, but keeping an open mind about the topic if you do not respond to the rehab itself.

 

Common Knee Osteoarthritis Symptom Treatment Fails Again

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knee osteoarthritis symptoms
Knee arthritis and steroid injections

 

Knee osteoarthritis symptoms. For some, it seems like the diagnosis is pretty much the same as saying that surgery is inevitable.

There are times when I think that more information is a bad thing.  There have been countless times in my practice where someone gets hooked on imaging findings (whether they are MRI, CT scans or X-rays) and focuses on what damage is present rather then what is reality.

Whether it’s a shoulder, low back, neck or knee imaging study, there have been multiple studies pointing out two very important problems.  First, there is very little correlation between imaging findings and symptoms.  In other words, if someone has “stuff” wrong on a MRI, it does NOT mean this person is going to have pain.  You cannot look at a MRI and state that this patient will or will not have pain.

This misconception then leads to the second problem.  There is a large chunk of the surgical field that is devoted to doing procedures based on stuff we find on imaging.  Got a disc bulge?  Cut it out.  Have knee osteoarthritis?  Replace the knee.  Torn rotator cuff?  Surgical repair of the shoulder.

This particular study highlights just how wrong this approach is.  In yet another study on the relationship between arthroscopic surgery of the knee for arthritis found on imaging and beneficial outcomes of the surgery, researchers looked at the results across 9 different medical trials.  Specifically, these middle aged and older patients with knee pain and degenerative knee disease underwent knee arthroscopic surgery.  Here’s what they found after an average of 2 years had passed after the surgeries:

  • There was a very small benefit to surgery in patients’ pain levels (basically, a benefit of 2.4 mm on a 0-100 mm scale).
  • There was no significant benefit on physical function.
  • Harms included symptomatic deep venous thrombosis, pulmonary embolism, infection, and death.

The bottom line is that, going in for surgery just to “clean out” the knee has virtually no benefit but a list of risks.  This is a procedure that, frankly, should no longer be done except in rare cases (and I don’t know exactly what these cases might look like…).

So what can you do instead of surgery?

  1. Move.  Not exercising is one of the worst possible things you can do for knee arthritis.  Hiking, swimming, weights, stationary bike, whole body vibration–there are lots of things you can do to strengthen your knees.
  2. Find a chiropractic who can competently treat the soft tissues of the knees–look for those that do Graston, ART, NMR, fascial manipulation.
  3. Consider a TENS unit to control the pain in the short run.
  4. Consider a joint support formula with glucosamine in it.
  5. Add vitamin D to your supplement list.
  6. Get down to your ideal body weight.

By using these tools to help manage your knee osteoarthritis symptoms, you won’t ever need to worry about whether or not the risks of surgery outweigh the miniscule benefits.

 

Having Orthopedic Surgery? You NEED to Know this Scary Risk

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orthopredic surgery and troponin
lenetsnikolai / Dollar Photo Club

Everyone knows that there are risks associated with any surgery. But the risks that you know about are the obvious ones.

Problems with the anesthesia such as aspiration pneumonitis or respiratory failure.  Problems with the surgery itself such as excessive blood loss, damaging the spinal cord or spinal nerves, infection or blood clots.

But what if there was something more insidious that can occur?  Something that won’t kill you today or tomorrow, but waits in the shadows until years later?

Before I tell you what this scary thing is, I do need to point out that there is a time and a place for orthopedic surgery.  But this should only be considered as an absolute last option.  All too often we THINK something is a last option.

But time and time again research proves that this is just not true.  Some examples:

This list is much longer, but you get the idea.  There are an uncountable number of orthopedic surgeries done every year that were unnecessary.  Which would be fine if there weren’t dangerous risks associated with orthopedic surgery and the chance that you will be no better after the surgery, or worse, in more pain after the surgery.

Side note–these comments do not apply to trauma-induced orthopedic surgeries–in these cases there are usually no options for avoiding an emergency surgery after trauma.

All of this brings me to this particular study.  In it, researchers looked at a scary side effect of orthopedic surgery called myocardial necrosis.  As you may be able to tell from the name, this is a condition were the heart muscle dies as a result of the stress on the heart from the surgery.  This bad effect from surgery is well known and characterized for short term mortality after orthopedic surgery.

What is not as well-known is what happens in the long term.  To get a better idea of how often this happens, researchers looked at levels of troponin (a protein found in the heart; elevated troponin levels are a sign that damage to the heart has occurred) immediately after orthopedic surgery and whether this related to long term death in hip, knee, and spine surgery 3 years later.  Here’s the details:

  • There were 3,050 surgeries with an average age of 60.8 years.
  • Myocardial necrosis occurred in 179 cases (5.9%) and heart attacks in 20 (0.7%).
  • In those patient who experienced myocardial necrosis, 16.8% of them did not survive in the long term (3 years).
  • In those who had normal troponin levels around the time of surgery only 5.8% did not survive.
  • To put it clearer, those orthopedic surgery patients who had higher levels of troponin were 233% more likely to die in the long term evaluation, while those who had a heart attack after the surgerys were 351% more likely to die.

Now certainly, if you had a heart attack just after your orthopedic surgery you’d know about it.  But myocardial necrosis may not have been fully explained to you if it had been identified.  Either way, if you DO end up having orthopedic surgery, it may makes sense to push your surgeon to run troponin levels along with everything else to get an idea about whether or not you’re going to be around in the next 3 years.

Seems simple enough.

 

Narcotics and Your Baby; Not a Good Combo

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opioid use during pregnancy
Maksud /Dollar Photo Club

You’re reading the title of this thinking that this is pretty stupid.  Who on Earth would think that this is a good idea??  Opioids during pregnancy.

I’m sure that if I gave you the true / false question, “Morphine is ok to take while pregnant,” there’d be no hesitation to check the “false” box.  And it wouldn’t surprise you at all to know that the use of morphine and morphine derivatives during pregnancy can lead to scary things like withdrawal symptoms into the newborn.  The technical term for this is Neonatal Abstinence Syndrome (NES).

If you agree that it’s absolutely crazy to take opioids during pregnancy, then you will likely be as shocked at the results from this particular study as I was.  In it, researchers looked at the use of opioids during pregnancy to evaluate just how common it was.  Here’s what they found when they looked at group of 112,029 pregnant women:

  • A shocking 28% (31,354) filled at least one opioid prescription during pregnancy.

How is this possible?  There are probably few people out there who would think that opioid use during pregnancy is ok.  I think I may know why; at least in my office.

From what I’ve seen, not enough of the population understand the drugs that they take.  Top culprits are Percocet and Vicodin.  It seems like a good chunk of my patients do not realize that these drugs are opioids.  Sure, most know that OxyContin and Oxycodone contain morphine derivatives.  But a surprising number of my patients over the years have not been aware that common pain medications that are handed out like candy also contain opioids.

So maybe a good chunk of the 31,000+ pregnant women in this study were written a prescription for hydrocodone-containing drugs like Percocet and Vicodin and just didn’t realize it.

Of course, the real question is how they got the prescription in the first place.  The prescribing physician should darn well know that opioids should not be prescribed in pregnant women.

The researchers then looked at what factors played a role in these pregnant women receiving a prescription for an opioid.  Here are the factors they found:

  1. They were more likely to have depression (5.3% vs 2.7%).
  2. Anxiety disorder (4.3% vs 1.6%)
  3. Smokers (41.8% vs 25.8%)

Looking at the list of these 3 factors, I just can’t understand how these patient-related factors should affect whether or not these women got a prescription for an opioid from her physician.

Overall, I don’t really have a take home message.  I’ve provided this article more for educational purposes rather than providing answers because I can’t understand how these prescriptions are written at this frequency.

In my biased opinion, the best and easiest answer to this prescribing problem is chiropractic care during pregnancy for any pain-related complaints instead of these prescriptions.  Maybe the answer is education for these pregnancy-related-opioid-prescribing physicians on the benefits of chiropractic care for pregnant women…??

NSAIDs, Prediabetes and Your Liver; Dangerous, but Not Like You Think

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elevated liver enzymes
creative soul/Dollar Photo Club

There is pretty much no chronic disease that prediabetes does not contribute to.  Fatty liver is on the list.

It goes by many names: non-alcoholic steatohepatitis (NASH), fatty liver, non-alcoholic fatty liver disease (NAFLD).  It can start with just a mild elevation of liver enzymes on a routine blood work panel.  This may prompt your doctor to order a viral hepatitis panel just to make sure that hepatitis is not at work.

When the virus panel comes back normal you just get kind of a mention of it not being anything significant and that we’ll just keep an eye on it.

This is how it starts (I’ve covered this concept in a previous blog article that can be read by clicking here), but it can progress to something far more severe with time, leading to scarring of the liver (fibrosis, cirrhosis) and liver transplants.

Currently, there is a rather large amount of research being published on this topic because this elevation of liver enzymes is on the rise.

As always, the answer comes down to that condition that about half of the Westernized world has prediabetes.  There are some very, very strong links between the diabetic progression and NASH.  It boils down to the accepted fact that the diabetic process pretty much pisses off the liver cells, ultimately killing them off slowly (leading to the elevation in liver enzymes in the blood).  Inflammation that is generated by the diabetic lifestyle likely plays a pivotal role as well.

This means that living an anti-diabetic lifestyle is the ONLY real answer (despite the rush to try to develop a drug for this condition).

(While it is beyond the scope of this article, feel free to check out my Diabetes eBook for a complete outline of the necessary lifestyle changes to combat diabetes by clicking here.)

Or at least, an anti-diabetic lifestyle was the only thing that USED to be on the list.  This particular article adds another aspect to this condition.  In it, researchers looked at the relationship between the activation of the enzyme cyclo-oxygenase 2 (COX2) and the development of fatty liver.

You may recognize the name of the enzyme because COX1 and COX2 are the enzymes that are blocked by the use of non-steroidal anti-inflammatory drugs like ibuprofen and naproxen.  And we can’t forget the Vioxx debacle, a drug that was designed to block only COX2, along with Celebrex and Bextra.

Vioxx was pulled off the market because it greatly increased the risk of heart attacks, causing at least tens of thousands of heart attacks in the time it was being prescribed.

Why?  Because, while we know that COX1 and COX2 produce inflammatory chemicals in our body, they also do things like thin the blood via the enzyme prostacyclin.  The problem is that we don’t find out about these other enzymes functions until we block it in large numbers in a brand-new-to-the-market blockbuster drug.

Here’s some interesting things that the researchers found:

  • Adult liver cells do NOT turn on the COX-2 enzyme when the rest of the body is in an inflammatory state.
  • This lack of expression of COX2 may leave liver cells vulnerable to the development of insulin resistance / prediabetes.
  • If the baseline production (constitutive) COX-2 in liver cells is forced (in the lab in mice), they found that this protects these cells against adiposity, inflammation, and, hence, insulin resistance.
  • This increased production of COX2 leads to decreased fatty liver, adiposity, triglycerides and free fatty acids, increased adiponectin-to-leptin ratio (an anti-diabetic marker), and decreased levels of chemical involved with inflammation.
  • As an added benefit, these mice who produced more COX2 enzyme activity burned more fat.

So, just like most everything else that has to do with human physiology, we really don’t have any idea how things work.  We THINK we know what enzymes do.  COX2 produces inflammation.  We block that with a drug and we’ll stop pain.

Until you cause a heart attack.

And here we see yet another aspect of what this enzyme does.  This leads to the very reasonable possibility that drugs like the NSAIDs and the selective COX2 inhbitors (Celebrex is still available although Vioxx was pulled off the market) may contribute to fatty liver.

Although it has always been known that these drugs damage the liver, it was thought to occur by a different mechanism; one that had not been previously thought of.  At least until now.

(Just in case you’re a little rusty on your ibuprofen side effects, feel free to check out my eBook on the topic by clicking here)

This is not, however, the direction the researchers were looking.  Rather, the conclusions stated that drugs that INCREASE the expression of COX2 in the liver may be a new route of research into drugs used to treat NAFLD.

Yep.  I’m sure it’ll be a blockbuster.  At least until it starts killing patients left and right.

 

Tylenol for Your Pain; Surprising Finding on How Well it Works

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Tylenol for back pain
Radosław Brzozo / Dollar Photo Club

Society would never consider going without over the counter pain meds. Doesn’t matter what’s it’s for; headaches, knee pain, shoulder pain, back pain.   We don’t seem to care where the pain is; that magical little pill hones in with radar precision to zap the pain and give you relief.

Or at least this is what the advertising messages would have you believe.

For starters, there is no magical honing; all drugs reach all areas of the body.  This is one of the reasons why so many side effects occur in organ systems that have nothing to do with the reason for taking a drug in the first place.

Personally, I haven’t taken any over the counter or prescriptive medications for at least 20 years (it may have been longer—I just can’t actually remember…) despite my share of martial arts injuries over the years.  But I certainly have my share of patients who take them on a regular basis.  We’ve become somewhat immune to the idea that every drug has a risk / benefit ratio.  There is not a drug out there that does not have side effects; since every single drug interferes with the way your body functions to some degree or another this is inevitable.

Paracetamol, the active ingredient found in Tylenol and generic acetaminophen, has a long list of side effects.  Just some of these include:

But, as mentioned, sometimes the side effects are worth the risk (although anyone on the liver or kidney transplant waiting lists may disagree…) so long as there are benefits.

But what if what you’ve been taking your Tylenol for really doesn’t work?  I can tell you that it certainly seems like many of my patients who are in pain and take many of the OTC pain medications aren’t jumping up and down for joy over how well they work (because, after all, they are in a chiropractor’s office looking for additional pain relief.

At the most, they seem to help “take the edge off” or help for a few hours at the most.  This particular study seems to agree with what I’ve experienced in my office.  In it, researchers looked across 13 different clinical trials looking at the use of paracetamol for back pain, knee or hip arthritis pain.  In the review, the researchers looked for the quality of the studies to see what the outcomes were.  Here’s what they found:

  • High quality results from the studies found that paracetamol is ineffective for reducing pain intensity and disability or improving quality of life in the short term in people with low back pain.
  • High quality results from the studies found that paracetamol used for hip or knee osteoarthritis for that any short-term improvement on pain and disability was not clinically important.
  • High quality results showed that those taking paracetamol were nearly four times more likely to have abnormal liver function tests.

When it comes to research, there are no absolutes and no single study can determine whether something works or not. To make it a little more complicated, there are good quality and bad quality studies.  But when you have multiple high quality studies pointing to the same outcome, you can be far more confident that the results from that study may apply to you.

That’s what we have here.  Could you be one of the few for whom Tylenol is going to work for back, knee or hip pain?  Possibly.  But it should not be your first choice given that there is a long list of side effects associated with the use of Tylenol and this review strongly suggests that it is not going to work.

Of course, being somewhat biased towards chiropractic care for these conditions, I would strongly suggest that chiropractic care should be your first choice for treatment of these conditions.

Knee Osteoarthritis Symptoms: To Use Steroid Injections or Not?

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knee osteoarthritis symptoms
Knee arthritis and steroid injections

Somewhere along the line steroid injections became the knee-jerk (pun intended) reaction for pain anywhere.

Shoulder pain?  Shoot it with some steroids.  Elbow pain?  Wrist pain?  Knee pain?  Scoot right on up and we’ll stick some corticosteroids directly into the joint.  Low back pain?  Despite the fact that there is very little evidence to support it, let’s go ahead and inject steroids into the sanctity of the spinal canal and see what happens.

When given orally, most would shudder at the random use of steroids given the risks of bone damage, obesity, diabetes and brain damage.  But given that it’s just a local injection it doesn’t affect the rest of the body.

At least, that’s what most people (doctor’s included) think.  Then why, in a prior blog article I did several years ago, did researchers find that it didn’t matter whether the injection was given directly into the shoulder or whether it was given in the buttock?  Because it does not matter.  Steroids, whether given orally, inhaled or injected anywhere, have an effect everywhere else in the body.

Because of this, we need to be darned sure that every use of steroids is going to have a positive effect on whatever condition it is being used for.  This definitely includes steroids being used for pain.  Which is why I bring you this particular article.

In it, researchers looked at whether the use of a cortisone injection for knee pain 2 weeks prior to a 12 week supervised exercise program helped in the long run or not.  All participants had arthritis of the knee on X-ray, clinical signs of localized inflammation in the knee as well as knee pain during walking (score >4 on a scale of 0 to 10).

The participants were evaluated using the Pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire (range, 0-100, where higher scores indicate greater improvement).  Half of 100 knee pain patients ended up in the steroid injection group and the other half in the placebo-injection group.  Here’s what they found:

  • After 14 weeks, those in the steroid group had a change of 13.6 on the KOOS score and those in the placebo group changed by 14.8 points.

Basically, the use of steroids led to a difference of 1.2 points (out of 100).  In addition, there were no differences in physical function, markers of inflammation or additional KOOS pain scores.

In other words, there were increased costs and increased risk of systemic damage from the steroids but no actual benefit.  Just to thrown a further wrench into the use of steroid injections for knee pain, it is entirely possible that the injection itself may have some benefits by disrupting blood vessels and bringing new nutrients and blood flow to the joint.  In other words, the benefits of the steroids may be even less (or worse-creating WORSE outcomes) because the injection portion of both treatments may have therapeutic benefits.

In case this STILL isn’t enough for you, it is very clear that any anti-inflammatory treatment damages the joint surface itself, preventing the cells from healing from future damage.  This means that, not only does the use of steroid injections for knee osteoarthritis symptoms not actually help, but you are damaging your knees for the future.

If you are wondering what else you can do to help your knee pain, feel free to check out my Knee Pain eBook on Amazon by clicking here.

 

Is Your Job Giving You Low Back Pain?

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occupational back pain
Is your job giving you back pain?

There are many factors that contribute to low back pain.  Some obvious, some not so.  But in many cases, these factors are under your control.

However, without some serious reworking of your life, you occupation is not easily changed.  But does your job contribute to your back pain?  Sometimes.

I hear it almost daily.  “If I just had a job that I didn’t have to sit all the time.”  “If I just had a job where I could sit down.”  The truth is that we are designed to be out hunting boars and gathering berries.  Not a whole lot of job openings for these positions, however.

I consider myself very lucky because my job has me up and down, sitting and standing, bending and straightening, pretty much all day long (unless I happen to be doing a blog post at my computer, of course).

There has been no real clarity in studies over the years looking for factors that predispose to the development of back pain.  Nothing can be clearly identified in a pre-employment physical that would indicate that a worker is more likely to suffer injuries.

However, there has been a consistent pattern over the studies on workman’s compensation injuries; those who are not happy with their jobs or feel unempowered are more likely to suffer an injury.  Not that anyone is faking an injury because he or she does not like his or her job; rather, this reflects the complex interplay between the mind and the body when it comes to pain.

This particular study, however, seems able to add some insight.  In it, researchers looked at 2,161 men working in various occupations across France who were followed across 5 years.  Twenty-one biomechanical, organizational, psychosocial, and individual factors were assessed in the first survey.  Five years later, in the second survey of these workers, they were asked about low back pain during the previous week.

Here’s what they found:

  • 394 (30.0%) men had low back pain in the second survey.
  • Frequent forward-only bending increased the risk of low back pain by 45%.
  • Frequent forward-and-sideways bending increased the risk 213%.
  • Driving industrial vehicles increased the risk 35%.
  • Working more hours than officially planned increased risk 38%.
  • Reported low support from supervisors increased risk 35%.

Notice that psychological factors showed up on this list again (low management support and working longer hours than planned).

There are other, general factors that play a role in low back pain.  Things like smoking and a sedentary lifestyle play a role in back pain, but these are easily modifiable.  If your occupation requires any of the behaviors or movements noted above, there is going to be a challenge.

The best you can do is manage your workstation, using back posture support devices when possible or lumbar support cushions if your job requires prolonged sitting or driving.  If you happen to own a company that uses team members who have to perform these repetitive movements, it might be well worth your while to invest in an ergonomic evaluation to see if any changes can be made to the workstation to minimize your team’s risk of low back pain.