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The “Red Flags” of Low Back Pain

15 Oct

Treatment guidelines published around the world note that ruling out “red flags” is a healthcare provider’s number one responsibility, which is in line with the decree exhorted by all healthcare professionals when first entering practice to do no harm. When detected, red flags prompt a doctor to stop and immediately send the patient to the appropriate healthcare provider or emergency department to avoid a catastrophic outcome, which may include death.

The four main red flags cited for low back pain include: cancer, fracture, cauda equine syndrome, and infection. In 1992, Dr. Richard Deyo reported that the patient’s history is more important for identifying red flags than a routine physical exam, especially in the early stages of these conditions. This is partially why new patients need to fill out so much paperwork on their initial visit. These are the factors that suggest red flags when it comes to low back pain:

Cancer: a past history of cancer, unexplained weight loss, failure to improve with a month of therapy, no relief with bed rest, and duration of pain over one month. However, when the combination of age over 50 years, past history of cancer, unexplained weight loss, and failure to improve with one month of therapy exists, the sensitivity or “true-positive” reaches 100%—in other words, IT IS CANCER until proven otherwise!

Cauda equine syndrome: acute onset of urinary retention or overflow incontinence, loss of anal sphincter tone or fecal incontinence, “saddle” anesthesia, and global or progressive motor weakness in the lower limbs.

Infection: prolonged use of corticosteroids (such as organ transplant recipients); intravenous drug use; urinary tract, respiratory tract, or other infection; and immunosuppressant medication and/or condition.

Spinal fracture: history of significant trauma at any age; minor trauma in persons over 50 years of age; patient over 70 years of age with a history of osteoporosis (with or without trauma); and prolonged use of corticosteroids.  A checklist that includes these important historical questions can be easily applied in any practice, which is highly recommended.

All healthcare providers—including chiropractors—managing patients in a primary care setting are obligated to rule out red flags in order to ensure patient safely when rendering treatment for LBP. The good news is that most cases of low back pain aren’t caused by these red flags and respond well to conservative chiropractic care!

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.
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Low Back Pain: Is It Your Feet?

6 Sep

The foot and ankle are unique in that their range of motion includes not only the front-to-back, hinge-like motion we associate with walking but also the lateral or side-to-side movement needed to change directions quickly. A problem in the foot can have a “domino effect’ that alters the biomechanics or the ankles, knees, hips, pelvis, low back, and even the neck—potentially increasing the risk of injury in each these areas.

Back in 1995, Rothbart and colleagues reported that hyperpronation—or excessive rolling inwards of the foot and ankle—is a leading cause of pelvic repositioning and mechanical LBP. Just watch people from behind as they walk in a mall, airport, or grocery store and you’ll notice almost everyone’s ankle rolls inwards as they step downward. To maintain proper foot posture, the use of foot orthotics is the most practical approach— coupled with wearing well-fitted, comfortable shoes, of course.

In a 2017 study, researchers recruited 225 adults with chronic LBP (more than three months) and randomly assigned them into one of three treatment groups: shoe orthotic (SO)-only, a “plus” group (SO + chiropractic manipulation/CM), or a waitlist group. The research team measured each participant’s pain and function/disability initially, after six weeks (the length of the treatment period), and then three, six, and twelve months later.

After six weeks, only members in the intervention groups reported any improvement in function. When comparing the waitlist and SO-only groups, the SO-only group demonstrated significantly greater improvements in both pain and function. The researchers also noted that members of the SO+CM group experienced even greater levels of clinically significant functional improvement.

This large-scale study supports the importance of examining the whole patient to identify and treat all factors that may contribute to a patient’s chief complaint.

 

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.

Low Back Pain: What Can I Do for It?

2 Aug

Low back pain (LBP) is the second most common reason for doctor visits in the United States and it is a condition that most of us will at some point in our lives. Last month, we reviewed the wide acceptance of spinal manipulation as the treatment of choice for both acute and chronic LBP.  This month, let’s take a look at what you can do outside the doctor’s office to self-manage acute and chronic low back pain.

One of the best self-management protocols for LBP is exercise that targets the lower back. It appears that the optimal time to engage in exercises for the lower back is during the work day since doing so may help alleviate some of the overuse and repetitive strain contributing to one’s LBP. Let’s focus on exercises you can perform from either a sitting or standing position during short work breaks…

RULES: Perform slowly to a full/firm stretch without pain; take three slow deep breaths for each; only do exercises that “fit” your job and time limits—this might be only one every fifteen minutes; make it work!

SITTING EXERCISES: 1) Sitting Forward Bends – bend forward and reach for the floor (as far as reasonably tolerated). 2) Sitting trunk rotations – twist slowly left, then right. 3) Cross Leg Stretch – cross one leg over the other; grasp and pull the crossed leg knee to the opposite shoulder while arching the back to its maximum until a firm stretch is felt in the buttocks.

STANDING EXERCISES: 1) Hamstring Stretch – place one foot on an elevated surface (like a chair seat, foot stool, or guard rail); perform an anterior pelvic tilt by arching your low back until you feel a firm stretch in the hamstrings. Switch sides and repeat. 2) Groin Stretch – do exactly the same steps as the hamstring stretch but this time, rotate your trunk to the side of the standing leg (away from the stretched leg) until you feel the stretch in the inner thigh or groin muscles. 3) Backward Bends – place your fists behind your low back and slowly bend backwards to a maximum tolerated point.

These “portable” exercises can be performed frequently throughout the work day, whenever you can spare 30-60 seconds. The most important point is to do these exercises on a regular basis. It may help keep your LBP from worsening during your workday.

 

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.

Low Back Pain: Spinal Manipulation vs. NSAIDs

2 Jul

Low back pain (LBP) is the single greatest cause of disability worldwide and the second most common reason for doctor visits. Overall, LBP costs society more than $100 billion annually when factoring in lost wages, reduced productivity, and legal and insurance overhead expenses.

Studies regarding the use of spinal manipulation(SM)—a form of treatment offered by doctors of chiropractic—for LBP are plentiful and have led to the strong recommendation that SM should be considered as a FIRST course of care for LBP. The American College of Physicians and the American Pain Society both recommend SM for patients with LBP who don’t improve with self-care.

In 2010, the Agency for Healthcare Research and Quality (AHRQ) reported that SM is an effective treatment option for LBP – EQUALLY effective as medication in reducing LBP and neck pain.

A 2013 study compared SM and non-steroidal anti-inflammatory drugs (NSAIDs) and found that SM was MORE effective than diclofenac, a commonly prescribed NSAID, for the treatment of LBP. Patients in the SM group also reported NO adverse side effects. More importantly, a 2015 study found that NSAID use can actually slow the healing process and even accelerate osteoarthritis and joint deterioration!

Doctors of chiropractic utilize SM as many conditions, including LBP— more than any other healthcare profession including osteopathy, physical therapy, medical doctors, and others. Chiropractors also combine other synergistic forms of care, such as patient-specific exercise training, to help patients learn how to self-manage their LBP, as recurrence is such a common issue.

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.

Low Back Pain: Who Will Respond Best to Care?

4 Jun

Is it possible to identify which low back pain patients might experience the most benefit from spinal manipulation combined with exercise? In a 2011 study, researchers identified which patients might respond best to this combination of care and which patients might need a more aggressive approach.

Directional preference (DP) describes a situation in which it feels better for the patient to move in one direction versus another. For example, if a patient feels worse bending forwards (which is quite common) and feels better bending backwards, then “extension-biased exercises” are preferred.

If leg pain is present, the DP that reduces or eliminates the leg pain (called centralization, or CEN) is the exercise-biased direction, and it’s important to avoid any exercise that increases leg pain (peripheralization).

In the study, which involved 584 patients with low back pain, the researchers found that 60% of the participants had a DP and of those patients, 60% had CEN. The researchers found that the patients with a DP that reduced CEN responded the best to care (in this case, spinal manipulation combined with exercise) in regards to improved pain and function. On the other hand, the patients who had no DP experienced the least overall improvement.

The value of using a classification system like this allows a doctor of chiropractic to determine which exercises will help each individual LBP patient the most.  It also provides them with the ability to identify those most likely to respond favorably and those patients who may need a more comprehensive treatment.

So, if you feel best bending backwards and/or leg pain lessens, the preferred exercises include bending backwards (extension) from standing, prone press-ups (“saggy” push-ups) or hugging a gym ball, and/or extending your back over a gym ball or a stack of large pillows. Of course, there are many additional exercises but ANY position that reduces LBP and/or leg pain will help.

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.

Low Back and Dysmenorrhea – Are They Related?

3 May

Dysmenorrhea, also known as painful periods, is a common gynecological condition that affects up to 70% of menstruating women. About 15% of individuals with the condition report that it significantly interferes with their activities of daily living (ADLs) and in some cases, results in absence from school and/or work. Studies have found that dysmenorrhea is related to early menarche (the onset of menstruation), nulliparity (not having children), and stress. But is it possible there’s an anatomical component to the condition?

The lumbar spine, or low back, consists of five vertebrae that rest on top of the sacrum, or tail bone, which is wedged between the “wings” of the pelvis (the ilia) making up the sacroiliac joints (SIJs). This close anatomical relationship with the pelvic organs suggests that the musculoskeletal dysfunction may play some role in dysmenorrhea. But is this truly an important relationship and if so, can spinal manipulation to the low back and pelvis/SIJs help reduce the pain associated with dysmenorrhea?

One study looked at the relationship between pelvic alignment and dysmenorrhea in 102 females divided into groups of those with and those without the condition. The researchers observed there were differences in pelvic alignment between members of both groups.

Another group studied the lumbo-pelvic alignment and abdominal muscle thickness in 28 women with primary dysmenorrhea and 22 women without the condition and found greater misalignment and smaller diameter abdominal muscles in the dysmenorrhea group.

To determine if there is a change in pain perception after pelvis manipulation in women with primary dysmenorrhea, a randomized controlled trial of 40 women (20 in two different groups) received a “global pelvic manipulation” (GPM) while the other group received a sham or placebo intervention. The participants in the GPM treatment group reported significant improvements in overall pain and sensitivity when compared with the sham treatment group, supporting manipulation as an effective tool in the management of dysmenorrhea.

Though further research is warranted, this study shows there is scientific support for the use of spinal adjustments in women suffering from dysmenorrhea. Therefore, chiropractic may offer an effective, safe, and often fast remedy for those who choose to not risk the side effects of various medications commonly used to treat dysmenorrhea.

 

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.