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Can the Outcome of Back Pain Be Predicted?

2 May

When patients present with low back pain (LBP), they are frequently nervous and worried about whether they’re going to respond to the treatment—especially when it comes to getting out of pain and returning to their normal activities. A variety of studies have shown chiropractic care to be an effective option for the LBP patient, and though there is no “crystal ball”, there are some tests that doctors of chiropractic can perform during an examination that can help predict outcomes!

In fact, a meta-analysis of data from 43 studies published since 2012 suggests that centralization and directional preference, which may be present in 60-70% of LBP cases, offers important prognostic clues. Directional preference means that it’s possible to move the body in a manner that feels better to the patient. Centralization implies that it’s possible to move in a way that reduces the range of the pain to a specific region.

Here’s an example… Let’s say an LBP patient presents with radiating leg pain from their lower back with numbness and tingling in the leg and foot. The focus is to find a movement that REDUCES the leg pain/numbness, so their doctor of chiropractic asks the patient to bend forward, backward, and sideways, and to rotate their torso, looking for which direction is preferred, i.e., directional preference. When pain decreases AND centralizes (the leg pain disappears), then extension is the directional preference.

When centralization occurs, this is a favorable prognostic sign indicating that improvement can be expected. Likewise, when all positions or directions increase leg pain, this is a poor prognostic sign, meaning this is likely a more challenging case.

This helps doctors better advise patients about their condition and what to expect from care in both the short and long term so the patient can make REALISTIC goals and timely plans. Over or under reassuring patients is simply not appropriate! Directional preference also allows providers a means of determining what type of treatment to emphasize. For example, if the patient feels better bending backward and leg pain disappears, the provider will approach treatment and exercise recommendations from that direction.

Patient education is an important part of treatment, and educating patients on how this process can predict treatment outcome instills trust and places realistic goals in perspective so patients know what to expect. This improves compliance with care and confidence for both the healthcare provider and the patient.

 

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

How Does Chiropractic Stack Up for Low Back Pain?

8 Apr

Doctors of chiropractic offer a non-surgical, treatment protocol for both acute and chronic low back pain (LBP), as do several other healthcare delivery systems. However, due to patient preference and a rising concern for potentially harmful side-effects, many LBP patients seek management strategies that offer a natural, non-pharmaceutical approach, of which chiropractic is the most commonly sought after practitioner-type. So what evidence is there regarding the benefits of chiropractic vs. other forms of care in managing LBP and its associated pain-related functional loss?

A 2018 study published in the online Journal of the American Medical Association focused directly on this question by comparing patient outcomes of those receiving usual medical care to a second group of patients that also received chiropractic care.

Data was collected at three sites—two large military medical centers and one smaller hospital at a military training site—over the 3.5-year time period. Eligible participants included active duty United States service members between 18 and 50 years in age who were diagnosed with mechanical low back pain.

Patients in each group received usual medical care for six weeks that included self-care, medications, physical therapy, and pain clinic referral. Participants in one group also received chiropractic care that included spinal manipulative therapy in the low back and adjacent regions and additional therapeutic procedures such as rehabilitative exercise, cryotherapy, superficial heat, and other manual therapies.

Up to six weeks after the conclusion of care, the researchers reported that patients in the  chiropractic group scored higher with respect to LBP intensity, disability, perceived improvement, satisfaction, and medication use. The researchers concluded that this trial clearly shows the need for chiropractic care for those suffering from LBP—reminding the reader that current LBP guidelines have embraced chiropractic care as a FIRST line of treatment for LBP.

This is not the first study to show the benefits of chiropractic care, as prior high-quality studies have reported higher patient satisfaction levels, less medication use, higher quality of life scores, and less LBP-related disability and recurrence rates for patients receiving chiropractic treatment vs. usual medical care. This article was published in a highly regarded medical journal (JAMA) and CLEARLY supports the need for chiropractic care in the management of LBP.

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Can Chiropractic Help Dysmenorrhea?

7 Mar

Primary dysmenorrhea (PD) is a very common gynecological disorder affecting 84.1% of women during childbearing age. The most common symptoms of PD include lower abdominal pain that can radiate to both thighs and/or to the low back. Other symptoms include tiredness, headache, nausea, constipation, and diarrhea. The condition precedes menstruation (in the absence of any organic pathology) and lasts approximately 48-72 hours. Primary dysmenorrhea is the most common reason for absenteeism from work or school, thus interfering with quality of daily life, which is associated with many direct and indirect costs.

There have been MANY proposed interventions for PD reported in the scientific literature. Most common are non-steroidal anti-inflammatory drugs (NSAIDs) and oral contraceptives, as both work similarly—they affect the cause of pelvic pain, which is reportedly mediated by the hormone-like fatty acid called prostaglandin factor 2x. However, both approaches carry negative side effects such as bleeding in the gut and hormone issues such as bloating and edema, respectively. Thus, the demand for new and alternative approaches with less associated risks has increased.

Spinal manipulative (SM) techniques for PD has been previously studied and proven to have positive benefits on pain perception and menstrual cramps, as well as affecting plasma (blood) levels of some chemical pain mediators. However, there appears to be a lack of agreement on where spinal manipulation should be applied. One study recommended that SM should be applied to the lumbosacral region (L5-S1) for symptom reduction in dysmenorrhea.

A more recent study found that “global pelvic manipulation” (GPM) performed on both sides of the pelvis to mobilize the sacroiliac joint (SIJ) and L5-S1 facet joint resulted in improvements related to low back pain and pressure pain thresholds in the SIJ, with a significant increase in serotonin.

Doctors of chiropractic specialize in the use of spinal manipulation therapy and are trained in many different techniques of lumbo-pelvic manipulation. For those struggling with PD, including a chiropractor as a member in your healthcare “team” makes perfect sense!

 

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

What is the Best Treatment for Chronic Low Back Pain?

7 Feb

When it comes to treating patients with chronic low back pain (cLBP), doctors of chiropractic commonly use a multi-modal approach that involves manual therapies, like spinal manipulation and mobilization, combined with supervised and/or home-based exercises. Why is that?

In many cases, the superficial paraspinal muscles of patients with back pain will tighten as a reflex in an effort to restrict movement and protect the area from further injury. Unfortunately, such a restriction can result in altered movement patterns that raise the risk for further injury (and pain) elsewhere in the lower back (or even in other areas of the body). On top of that, because the superficial back muscles have abnormally assumed the job of maintaining posture, the deep muscles in the back can become deconditioned and weak, which only raises the risk for further back issues.

So, when it comes to chronic back pain, the job of a chiropractor is two-fold: restore proper joint motion to “turn off” this abnormal reflex muscle spasm and to strengthen the deep muscles so the superficial muscles can return to their normal function.

In a 2011 study, researchers randomly assigned 301 cLBP patients (adults over 65 years old with a five or more year history of chronic low back pain) to one of three treatment groups: supervised exercise therapy (SET); spinal manipulative therapy (SMT), or home exercise and advice (HEA).

Researchers monitored each participant’s progress for over a year and found that members of each group achieved similar short- and long-term improvements with respect to pain, disability, global improvement, general health status, and medication use. Though the patients in the SET group experienced greater gains with respect to trunk muscle strength, endurance, and range of motion in comparison with the home-based exercise group, the difference in results is understandable as the SET protocol was much more intensive.

Though this study did not specifically look at the effect of combining exercise and spinal manipulation for the treatment of cLBP, several guidelines that have looked at the available evidence recommend using such a multi-pronged approach for this group of patients. For example, in 2018, the Canadian Chiropractic Guideline Initiative wrote, “A multimodal approach including SMT, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain.”

 

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

A Less Obvious Cause of Back Pain?

3 Jan

Multiple studies have shown that hyper-pronation (HP), or too much rolling-inwards of the ankle, can have effects on the body far beyond the foot. For example, abnormal motion of the ankle can lead to slight changes in how the knees and pelvis move as you carry out your normal daily activities, placing added strain on these structures and increasing the risk of injury in both the short and long term. These faulty movement patterns can also lead to improper motion and a higher risk for injury above the hips, including in the lower back.

In one study that involved patients with low back pain (LBP), researchers found that improving both ankle pronation (with foot orthotics) and lower limb weakness (with exercise) resulted in improvements in knee, hip, and low back function.

Foot orthotics often include a lateral heel wedge to correct the rolling-in effect of the ankle. One study measured the effects that a 5º heel wedge had on the lower limb up to the thorax, noting significant 3-dimensional kinematic changes occurred on the hip, pelvis, and thorax. However, over-correction (at 10º), had detrimental effects on proper motion elsewhere in the body, which underscores the importance of getting an accurate prescription when fitting foot orthotics. Likewise, other studies have demonstrated that a forefoot orthotic may also be required to ensure proper biomechanics while walking.

A study that included 213 high school and college cross country runners (107 male, 106 female) found that 37 (17.4%) wore foot orthotics. Of the 37 orthotic users, 17 (54.8%) wore them for exercise-related leg pain, of which 15 of the 17 reported benefits. Another study compared the load on the Achilles tendon during running both with and without foot orthotics and reported that running with foot orthotics was associated with significant reductions in Achilles tendon loading compared to running without orthotics.

These studies clearly support the MANY benefits foot orthotics have on the whole body or structure, which facilitate both the short- and long-term management of conditions like low back pain! Doctors of chiropractic frequently fit foot orthotics for lower extremity complaints, as well as LBP.

 

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.

Back Pain: Does Maintenance Care Work?

3 Dec

Non-specific low back pain (nsLBP) is one of the most common and costly healthcare problems affecting society, and it is also the leading cause of activity limitation and work absence around the world.

Following a course of treatment to reduce pain and improve function for patients with a musculoskeletal complaint—such as back pain—doctors of chiropractic commonly make recommendations to reduce the risk of a future episode (or at least minimize its severity should one occur). These recommendations may include adopting a fitness routine, dietary modifications, specific exercises, foot orthotics, and/or routine “maintenance” chiropractic adjustments, such as once a month or every six weeks.

Though further research is necessary to more clearly understand precisely how maintenance care (MC) works to reduce the risk of future episodes of back pain, researchers currently hypothesize that such treatments may improve any biomechanical or neuromuscular dysfunctions before they become symptomatic.

Studies published in both 2004 and 2011 note that patients with chronic low back pain who received maintenance care for nine months reported less pain and disability than participants who did not receiving ongoing care.

In a 2018 study that included 328 nsLBP patients, researchers found that those who received ongoing maintenance care following their initial course of treatment experienced 12.8 fewer days with LBP over the following year. Compared with patients who were advised to return for further care on an as-needed basis, the participants in the MC group only made an average of 1.7 additional chiropractic visits during the study.

The authors of this study concluded, “For selected patients with recurrent or persistent non-specific LBP who respond well to an initial course of chiropractic care, MC should be considered an option for tertiary prevention.”

This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.