LifeCare Chiropractic

The Best Chiropractic Care in Mesa, Arizona

Work Injuries

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.

 

Chiropractic: The Red-Headed Stepchild of Injured Workers’ Care

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chiropractic care for injured workers
Photo courtesy of https://www.flickr.com/photos/pamhule/

As a practicing chiropractor here in sunny Mesa I can tell you that seeing injured workers in my office is a rare event.

Even rarer is a patient who was injured at work who was sent in by his or her HR department to my office for care.  Almost always it is a current patient who was injured at work and wants to be seen in our office for care because they know how effective we are.

It is rare for me to get frustrated over anything, but having a representative for a patient’s workman’s comp insurance tell me “we don’t refer to chiropractors” just irks me to no end.  Even worse is an existing patient who comes in for care of a work injury and then is told, ILLEGALLY, that they can’t come into our office for care.  The worker is scared to go against his or her employer, even after assurances by us that they can see us for treatment.

Here in AZ, with a few self-funded exceptions, patients all have a right to see the provider of their choice.  They may be required to make a single visit to a provider that is chosen by the employer, but that is all they have to do.  However, once they have seen a provider twice, that provider controls all care for the course of the injury.

So the patient sees the provider that the employer requires.  That provider (which is almost always one of the two larger occupational or urgent care clinics that use PTs for treatment) then coerces the patient to come back for another visit under one pretense or another and they get them back in quick.  Frequently the next day.

The patient ends up falling into the scheme and is NEVER given his or her rights, which would be to see a chiropractor if he or she chose to.

I would just be whining and complaining in this article if it weren’t for one important fact…

It’s a very, very bad idea to NOT see a chiropractor first or at least have one on the care team as soon as possible.  Why?  Here are a few of the reasons:

  1. The alternative is far more costly.
  2. Patients take longer to get back to work and are more likely to become disabled.
  3. Medications that actually promote chronicity are more likely to be used.
  4. Patients are generally not as happy with the care they receive.

As a chiropractor one would think that I’m just being petty and biased.  But regular readers of the Rantings know that I can back up everything that I put in writing.  This is no exception.

In this particular study, researchers looked at 14,787 injured workers over the course of 8 years to evaluate care patterns for low back pain.  They identified 5 distinct patterns of care for the injured workers:

  1. Information and Advice (59% of injuries): The first 6 weeks basically consisted of information gathering or advice seeking but no overriding pattern.  This included simple office visits, laboratory tests, emergency department or hospital visits, talk therapy, or visits involving imaging (x-ray, ultrasound, CT, or MRI) but no other procedures.
  2. Complex Medical Management (2% of injuries): Included more than a single visit to a physician for nerve blocks, surgeries, or comparable procedures.  This is expensive and fragmented care and runs completely contrary to the way low back pain should be managed.
  3. Chiropractic (a paltry 11%):  Self-explanatory.  Used by the most intelligent injured workers (ok…so I made this part up).
  4. Physical therapy (11%):  Self-explanatory.
  5. Dabble (17%): Workers who had one visit to a non-chiropractic physician, chiropractic physician or PT, or at most one visit to two or more of these categories.

Overall, being good at math, it looks like 89% of the injured population were not under the care of a chiropractor.  Keep this in mind as we go through the rest of the study.  I know that here in AZ, this low percentage is likely a result of steerage by the insurance company, HR employees who do not understand how effective chiropractic care is, as well as the schemes played at the patient’s expense by other providers that treat injured workers.

After identifying the 5 patterns, researchers looked at well accepted guidelines for the treatment of low back pain that is backed up by medical research.  There were 11 guidelines that were used to evaluate the 5 treatment patterns, but here are some snippets to think about:

  • Early use of (MRI) has been linked to prolonged disability, higher medical costs, and greater use of surgery at the same time finding no benefit on health or disability outcomes for low back pain.
  • Chiropractic has been shown to lead to lower likelihood disability recurrence over non-chiropractic physicians and physical therapists.
  • In addition, chiropractic care with shorter duration (likely meaning more effective chiropractic care that seeks to get the patient better ASAP) also leads to shorter disability duration.
  • More frequent and stronger dosages opioids leads to longer claim durations.  Worse, the likelihood for a catastrophic claim (total cost of $100,000 or more) when spinal surgical procedures were performed increased 10-fold when treatment included opioid use.

It goes without saying that chiropractic care is the antithesis of opioid use.

With all this in mind, here are a few snippets from the study:

  • Care to injured workers that was in line with 10 of 11 guidelines led to lower total costs.
  • Of the five patterns, complex medical management followed the guidelines the worst in regards to imaging, surgeries, and medications as well as having the highest total costs.
  • Complex management was also linked to the highest rates of prescriptions for four of the seven drug classes—opioids, other pain medications, SSRI/SNRI/tricyclics, and anxiolytics/sedatives/hypnotics.
  • The PT group was highest in NSAIDs, muscle relaxants, and oral steroids.
  • Chiropractic care was on the opposite end of the spectrum, leading to the most alliance with accepted guidelines, lower total costs and the lowest prescription rates in all seven classes of drugs.
  • Previous treatment choices by injured workers influenced future choices for another injury.  This means that, if someone did NOT choose chiropractic care for an initial work injury, if they got injured again they were not likely to seek chiropractic care for the second episode.

There is really not much more to say.  Except that maybe all of this information is not new and is consistent with the findings from a large handful of other studies.  Hopefully you can understand my frustration with the care of injured workers here in Arizona, as well as the extreme confusion when it comes to chiropractic care being treated as the red-headed stepchild of healthcare when, in reality, we really rock when it comes to doing what we do.

By avoiding or discouraging chiropractic care for injured workers here in AZ, workers are not getting the best and most cost-efficient care possible.  That, quite frankly, is a travesty.

 

Will I Need Surgery for My Carpal Tunnel?

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There are some conditions that we have been conditioned to believe need surgery.  Knee meniscus injuries, disc herniations, rotator cuff tears. Carpal tunnel is on the list as well

I recently had a new patient come into my office on a Monday.  He’s 66 and had been scheduled for shoulder replacement surgery 4 days later on Thursday, with the other shoulder to follow a few months later.  Not an easy surgery nor an easy recovery.

However, he started to develop numbness over both of his hands, with the numbness covering all 5 fingers.  He mentioned to his orthopedic surgeon that he did not think he could manage the rehab from the shoulder with his hands being this numb.  So this man has an NCV test done (a nerve conduction velocity test that can tell how well the nerves in your arms or legs are firing) that came back with a diagnosis of carpal tunnel syndrome.

I pretty sure that every NCV test report I have ever read comes back with carpal tunnel.  Even the ones done on the legs…  I think it is just a factor of how much we use overuse our hands in daily life on the computer, texting and writing.

So, with the NCV in hand, the surgeon cancels the shoulder surgery and slides a carpal tunnel surgery in place instead.  So now this patient is facing 4 surgeries in the next 6 months or so.

For those of you shaking your heads in disbelief, let me reaffirm your wonder.  No conservative care.  No rehab.  No splinting.  No injections.  Nothing.  Just straight to the knife.

For those who are not well versed in anatomy let me give you a little tidbit on what fingers the median nerve (the nerve affected by carpal tunnel) feeds.  Basically, it’s the thumb and next digit (technically, it’s the lateral 2.5 digits, but most patients can’t notice the ½ so they just note numbness over the thumb and adjacent 2 fingers).  It does NOT feed the palm—the superficial palmar branch of the median nerve branches off just before the carpal tunnel.

Now that you’ve brushed up on your anatomy, we can go back to my patient.  Remember when I said his entire hands were involved?  That is absolutely, positively not consistent with carpal tunnel syndrome and is usually more related to the shoulder (subscap trigger point referral or anterior scalene or pec minor impingements).  That’s not to say this gentleman did not have  carpal tunnel, but the picture was far more complex.

I explained all of this to the patient as well as giving my opinion that surgery was completely inappropriate without at least a trial of some type of conservative care.  We treated him that first day and left the decisions up to him.

Needless to say, he canceled his surgery, we saw him again on Wednesday and on Friday, before he was treated, he was shocked that the numbness in his hands was completely gone and was asking what we might be able to do for his shoulders.  There’s a chance I’m going to have one pissed off orthopedic surgeon on my hands.

This doesn’t mean that he was cured after 2 visits, but it certainly means we’re on the right track.  But all of this leads back to this particular article, looking at how much injections for carpal tunnel work or don’t work.

Three groups (37 patients each) of patients received 80 mg of methylprednisolone, 40 mg of methylprednisolone, or placebo injections for carpal tunnel.  All of these patients had been given a splint to help treat his or her carpal tunnel and it was unsuccessful.  Here’s the results:

  1. At 10 weeks those who got the injections did better (36% @ 80 and 12% @ 40).
  2. One year later, there were no differences between the groups.
  3. The 1-year rates of surgery were 73%, 81%, and 92% in the 80, 40 and placebo groups.

Basically, 75% of the carpal tunnel syndrome patients in this study had surgery.  That pretty much means that injections for carpal tunnel suck at actually fixing the problem.

Lest the carpal tunnel sufferers out there begin to despair, let me throw in a few comments.

First, the is much evidence that both NSAIDs and steroids actually interfere with healing.  It may very well be that the injections themselves will prevent long term healing.

Second, the carpal tunnel is a tight tunnel, made of bone on one side and the steel-like flexor retinaculum on the other side.  Through this tunnels, 9 tendons and one tiny little soft nerve run.  When the tendons swell, the median nerve is smashed like a toddler stuck in an elevator with the entire defensive line of the Vikings.  So we put blinders on and try to control the swelling with drugs or injections, and when that fails we just go in there and make some snips, so the swelling can continue without creating a problem.

But what caused the swelling in the first place?  While it seems like the obvious question, it’s almost never asked.  In my experience, fascial / muscular problems in the forearm (both the front and back side) create a situation where the tendons are put under increased strain and begin to swell, creating the symptoms known as carpal tunnel.

ANY treatment of carpal tunnel has to address this aspect of the problem.  If not, treatment is doomed to fail from the start.  And this does NOT involve exercise; rather, it involves competent soft tissue work to the forearm and shoulder if needed.

In this study, all that the patients received was splinting, which does nothing to fix the problem but just allows the swelling to go away for a short period of time.  It was doomed to fail from the start.

Foot Bone Connected to the Back Bone = Less Pain Meds??

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work place injuries chronic low back pain
orthotics and work place injuries

We all know the human body is connected, and for a chiropractor, some of these relationships are old hat, especially when it comes to back pain.

I’ve just started to participate in an Industrial Commission of Arizona ad hoc committee on chronic pain management, although one of my colleagues has been on the panel since it started and has a much better idea of the objectives of the committee.  However, even in my first meeting, there seems to be a heavy focus on medication management and pain management (which includes all the types of injections used for chronic pain).  There is very little focus specifically on manipulation and chiropractic care–it is just lumped together under “conservative care.”  And here in the workman’s compensation arena in Arizona, chiropractic care is microscopically small chunk of this conservative care.

Given how incredibly effective we are (chiropractic care is the most efficient model of care delivery in healthcare today for non-surgical spinal complaints, and leads to an overall 30% cost savings across the board which translates into BILLIONS of dollars saved), this omission is glaring.

So what does all this have to do with this particular study?  Chiropractic care does NOT equal manipulation, although this is a tool heavily used in a chiropractic office.  Rather, most chiropractors will utilize a wide variety of tools to help patients manage pain, both acute and chronic.  These can include:

  • manipulation
  • TENS units
  • exercises / rehab
  • home instructions
  • counseling on long-term management / avoidance of flare ups
  • stress management
  • heel lifts / orthotics

I know that in our office discussions on pillows, sleeping positions, sleeping surfaces, the absolute need to move around and exercise, ergonomics, stress management and occasionally inversion tables and at-home cervical traction collars are pretty much a daily thing.  The point is that chiropractors are, in general, one of the most competent providers in the health care system for managing pain.  Of course, my opinion may be slightly biased, but I can, as usual, back up this bias with solid evidence.

Now, if I can direct your attention to the last bullet point above, orthotics, we can get back to the study.

Researchers took a group of 62 patients presenting with chronic (longer than3 months), nonspecific, low back pain after suffering a work-related low back injury and followed for 6 weeks.  The groups were split up into:

  1. About half the patients when given usual care, which consisted of a 6-week exercise therapy program along with prescription pain meds.
  2. The other half received the same therapy in addition to customized foot orthotics.

Our office has used a computerized gait analysis system for almost a decade now (I think maybe it’s time to upgrade the software…) and the orthotics are made based on the data obtained from walking across a pressure plate during a normal walking pace.  Pretty cool to be able to see how your foot strikes the ground.  This information can be very helpful for those suffering from low back pain.  Support the arches (especially if your work duties involve standing for prolonged periods) and control the shock of the heel striking the ground and this can really be the final piece of the puzzle to help resolve or better control chronic low back pain.

So what did the researchers find 8 weeks later?

  1.  Both groups had improved.
  2. The orthotic group had a lower disability scores (as measured by the Oswestry Disability Index).
  3. Those in the orthotic group were using less pain meds by the end of the study period.

Pretty impressive for a simple intervention with almost no downside.  On top of that, the money saved on the medications alone would likely pay for the orthotics.

The bottom line is that, whether you’re suffering from a chronic work place injury or chronic low back pain unrelated to a work injury, make sure you ask your chiropractor if he or she thinks orthotics may help your chronic low back pain.

 

FASCIA INFLUENCES MUSCULOSKELETAL DYNAMICS – (12-04-06)

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Active fascial contractility: Fascia may be able to contract in a smooth muscle-like manner and thereby influence musculoskeletal dynamics

There is a manual therapy technique out there in “technique world” called Graston technique. I know here in AZ there are currently only about 8 certified practitioners, of which I am one. I have been a part of this technique working “miracles” on patients who have had problems that have been present for, in some cases, decades. There’s actually nothing miraculous about it, it’s just that it is one of the best methods I know of that effectively addresses the fascial component of injuries/conditions. The Rolfers have been privy to this since their existence.

This article helps delve into the concept that the fascia can actually play an active role in drastically increasing muscle tension and that problems with this network can lead to chronic problems.

Read entire article here

INVESTIGATION OF AXIAL SYMPTOMS AFTER CERVICAL LAMINOPLASTY – (08-28-06)

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Investigation of axial symptoms after cervical laminoplasty, using questionnaire survey

While the results of this study should come as no surprise, it is rather unusual for a group of orthopedic surgeons to denounce a particular surgical approach. I can honestly say that it is rare for anyone in my office to end up going through surgery if they stick out a treatment plan. But, I’m pretty strong on the fact that soft tissue work HAS to be a component of a solid musculoskeletal treatment. Couple this with some good ole’ fashioned adjusting, and most patients can avoid surgery.

Read entire article here

DO NOT IGNORE HEADACHES – (06-06-05)

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Headache, cerebrovascular symptoms, and stroke

Headaches, regardless of the type or label, are an indication of something wrong.  Whether physiology is imbalanced, whether the body is toxic and the brain is revolting, whether the headache has a musculoskeletal cause.  There is nothing “normal” about a headache.  Covering up the symptoms with medication without truly addressing the problem should be considered malpractice, but unfortunately it is the standard of care.

This article once again perfectly illustrates this concept.  The patient with migraine w/ aura is put on drugs to stop the migraine, and yet, in the background, the patient’s risk of stroke symptoms goes up 5 and a 1/2 times.  This is NOT good medicine.  It also further illustrates that migraines are a manifestation of a systemic problem and need to be addressed through lifestyle changes that will also lower their risk of strokes.

Read entire article here

 

DECLINE IN SKELETAL MUSCLE MITOCHONDRIAL FUNCTION – (05-16-05)

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Decline in skeletal muscle mitochondrial function with aging in humans

While we know that skeletal muscle declines with age (a condition referred to as sarcopenia) but the exact mechanism has not been pinned down.  Less building of muscle?  Increased breakdown?

This article points to my particular “demise of Western civilization as we know it” reason which is oxidative stress and mitochondrial dysfunction.  While my wife does not enjoy my deep discussions of mitochondria oxidative phosphorylation over dinner, when my “mitochondrial dysfunction as the root of all evil” book hits the shelves as a bestseller I’ll be able to stick my tongue out at her…

Read entire article here