back pain

Why You Need a Back Specialist for that Sore Lower Back

October 16, 2012 by James Bogash

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?

WHAT HAPPENED AFTER YOUR MRI?

October 11, 2011 by James Bogash

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.

I CAN’T SEE A CHIROPRACTOR–I’VE HAD SURGERY!

September 22, 2011 by James Bogash

This is certainly a phrase I’ve heard many times in the community. Usually someone stating that there is nothing that chiropractic can do to help them because they’ve already had surgery.

Obviously, seeing a chiropractor BEFORE the surgery in the hopes of avoiding the surgery altogether is the preferred method, but should you miss that opportunity, fret not. Somehow, when patients unfamiliar with chiropractic care envision a treatment session in a patient who has had surgery or maybe has osteoporosis, it involves the chiropractor jumping off from the desk to deliver a ninja-like adjustment.

I know that in our office, with the heavy soft tissue approach, we have been able to provide significant relief to those patients who have had surgery and who thought that there was nothing that could be done to help with their pain levels.

While this study is a case series and involved lumbar surgeries (the best response being those with the more invasive surgeries), we have seen both neck, ankle, wrist, shoulder, knee and low back surgeries that did not resolve the complaint but responded well to care in our office.

So, next time you hear someone say that they can’t see a chiropractor because they’ve had surgery, point out this study.

SPINAL ARTHRITIS – DO I NEED SURGERY?

June 29, 2011 by James Bogash

Pretty much every day I address this question from patients. They come in after having an X-ray or MRI done after a few weeks of untreated back pain and may even have their orthopedic surgeon appointment set up. The problem remains that there is very little correlation between what we see on imaging and pain levels of a patient.

As a matter of fact, this is probably one of the bigger educational challenges I have in my practice because society has brainwashed into thinking that all the answers lie in the MRI or X-ray and they are infallible. I can’t tell you how many times I have had patients come in with knee pain due to “arthritis.” However, after 2 or 3 visits they are greatly improved. We obviously did nothing to magically get rid of the arthritis, but the arthritis was not the pain generator for this patient.

This particular article reinforces this same concept for back pain, with a specific focus on those over 60 years of age. The researchers found a very high level of arthritis of the spine (75.8%), but only a small portion (28.8%) had back pain. And again, referring back to the knee example above, how many of these patients with back pain would still have symptoms after a solid course of chiropractic care coupled with soft tissue treatment?

The bottom line is that arthritis is something we see on X-rays or on MRI, but it is merely the canvas on which your symptoms may be painted. Only rarely is surgery in these cases a good idea with a good outcome. Without a doubt, your best first option for any type of pain is a Mesa chiropractor. And this is NOT my bias, but rather, strongly supported by claims data from insurance companies and clinical studies.

http://ard.bmj.com/content/68/9/1401.abstract