Think Out of the Box
By
JCS
The paradox of low back pain has received enormous attention lately for good reasons. Different approaches and treatments abound among practitioners of different skill levels. Considering the huge costs involved in this epidemic, the consensus of spine researchers and governmental guidelines has startled the medical profession with new findings and recommendations that I would like to share.1
“A disease like back pain can have a lot of variability in the ways medical professionals approach patient care,” according to Scott Boden, MD, director of the Emory Orthopaedic and Spine Center in Atlanta. “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”2
Indeed, LBP has become a “think out of the box” problem because the standard medical approach for LBP—pain pills, muscle relaxants, injections, physical therapy modalities, MRI scans, disc surgery—has now been shown to be expensive and clinically ineffective. “Low back pain has been a 20th century health care disaster,” according to Gordon Waddell, M.D., orthopedist and spine researcher. “Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem.”3
Muscle Relaxants: Overused, Ineffective
Ostensibly the common LBP diagnosis is “pulled muscles” or “slipped discs,” and the routine treatment is pain pills and muscle relaxants in 63% of cases. In a recent issue of Spine, researchers found in patients with severe acute LBP, muscle relaxant use was associated with a statistically significant increase in time to recovery — 32.4 days compared to 16.2 days in the placebo group, due to the sedative effect upon patients. The researchers concluded there was “no demonstrable effect from muscle relaxant use.”4
MRI “False Positive” Imaging
After medications fail to solve most LBP symptoms, the second avenue by PCPs calls for the use of MRI scans to detect herniated or degenerated disc problems. However, “best practices” guidelines question whether or not scans are necessary in light of the cost and ubiquitous nature of disc abnormalities.
“It should be emphasized that back pain is not necessarily correlated or associated with morphologic or biomechanical changes in the disc,” according to Dr. Boden. “The vast majority of people with back pain aren’t candidates for disc surgery.”1
Agreeing with Dr. Boden is another leading spine researcher, Richard Deyo, MD, MPH, University of Washington Medical School, who criticized “Old concepts supported only by weak evidence,” and the reliance on MRI exams to infer disc abnormalities as the cause of back pain. In The New England Journal of Medicine, he debunks the outdated disc theory that often leads to a “false positive” misdiagnosis:
“Early or frequent use of these tests [CT and MRI] is discouraged, however, because disc and other abnormalities are common among asymptomatic adults. Degenerated, bulging, and herniated disks are frequently incidental findings, even among patients with low back pain, and may be misleading. Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”5
Unnecessary Disc Surgery
This is the main paradox of medical analysis and treatment of LBP—the unsupported assumption that the disc theory is valid despite the weak evidence from MRI exams as Boden and Deyo suggested. If EBM is to succeed with LBP, this is the main assumption that must be disspelled.
The Agency for Health Care Policy and Research, a 23-member panel headed by orthopedist Stanley Bigos, MD, unquestionably the most in-depth meta-analysis of acute LBP in 1994, confirmed the rare need for surgery:
“Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.”6
Obviously any treatment won’t do much good if the diagnosis is incorrect. Indeed, an MRI finding of disc abnormalities alone is not a diagnosis, moreover, some causes of pain will not show up on an MRI scan, primarily the mechanical inability of the spine to bear weight and the overall alignment, strength, and flexibility of the spinal column. Rather than focusing on a few disc abnormalities, the overall function of the spine is often ignored. Indeed, it’s not being able to see the forest through the trees.
In other words, scientists now believe that most idiopathic LBP is mechanical in nature. Dr. Deyo acknowledged that most back pain is “mechanical” in nature, meaning joint/muscular dysfunction. According to his article, “Differential Diagnosis of Low Back Pain,” Dr. Deyo opined that “Mechanical Low Back or Leg Pain” constituted 97% of these cases, of which “lumbar strain, sprain” accounted for 70% of these cases; “Nonmechanical Spinal Conditions [disc, infections] accounted for “about 1%”; “Visceral Disease” [referred pain] accounted for 2%.”5
Spinal Joints: The Forgotten Problem
If not “pulled muscles” or “slipped discs” causing idiopathic LBP, what does? Obviously the overlooked cause in idiopathic LBP by most PCPs may be the fact that, aside from 23 discs, the spine has 137 joints altogether. Any diagnosis for LBP or any spinal problem must include proper joint play, muscular strength, and overall flexibility of the spine—the “forest,” if you will.
There is now broad agreement in medical practice that surgery should not generally be considered until there has been a trial of conservative non-surgical care, primarily spinal manipulative therapy. 7,8,9 The AHCPR panel recommended spinal manipulation as a “Proven Treatment” and the preferred initial professional treatment for low back pain. This guideline states:
“This treatment (using the hands to apply force to the back to ‘adjust’ the spine) can be helpful for some people in the first month of low back symptoms. It should only be done by a professional with experience in manipulation.”6
Many medical researchers now suggest that the effectiveness of skilled manipulation can primarily be explained as the alleviation of pain from overlying facet joint dysfunction or, in chiropractic parlance, the vertebral subluxation. 10,11,12,13
SMT for HNP?
Many physicians now understand that back pain alone very rarely requires surgery, but the question concerning LBP with sciatica presents another consideration: can spinal manipulative treatment be as effective as spinal surgery for disc herniation? Yes it can!
The latest studies suggest that SMT and spinal axial decompression may be the best methods for the majority of these cases. Several studies have recently shown that 50-80% of patients with lumbar disc herniation are relieved by side-posture manipulation.14,15,16,17
The largest study by Kuo and Loh16 involved a series of 517 patients over an eight-year study period. All had a diagnosis of lumbar disc protrusion and were referred for manipulative therapy. 77% had a favorable response, defined as relief of pain at least to the extent that the patient could perform daily activities.
Buckled Joints
In my 25 year career as a spinal practitioner, let me give you my learned “best practices” opinion. The accumulative effect from traumatic injuries during childhood compounded in adulthood by the effects from gravity such as prolonged sitting/standing, improper lifting, and obesity will overload a vertebral motor unit and develop into a functional spinal lesion caused by a “segmental buckling effect,” according to research by John Triano, DC, PhD, et al. at the Texas Back Institute.18
In other words, most LBP may not be caused initially by a slipped disc as much as by slipped joints that have buckled. This also may explain why a patient doing perfectly well one moment may suddenly experience an excruciating back pain while virtually doing a minor act.
Indeed, it’s the proverbial straw that broke the camel’s back—a back injured in childhood never mechanically corrected, weakened by a sedentary lifestyle in adulthood, a weakening core strength, thus becoming an accident waiting to happen.
“But all I did was…” so explains the bewildered patient but, upon examination, spinal x-rays show an arthritic spine with many areas of structural misalignments from years ago. The buckled spine in turn causes the reflex muscle spasms, disc herniation leading later to degeneration, facet syndrome, nerve inflammation and, of course, back pain.
The altered joint mechanics is now believed to be the primary cause of pain and protrusions, which explains why SMT has proven effective in these cases and why many disc surgeries fail.
Spinal Decompression with DRX9000
Certainly not every LBP patient responds to SMT, especially those with failed back surgery syndrome, infectious pathologies, cauda equina, stenosis, referred pain, etc. However, for the majority of idiopathic HNP cases, spinal axial decompression therapy has also proven very effective in treating disc herniation and degeneration with an 86% success rate according to extensive research by CN Shealy, MD, PhD.19
Unlike the VAX-D straight linear traction that is non-specific like the old traction tables, the DRX technology uses angled distraction specific to each lumbar intervertebral disc, applying about 80-90% of pull to a single disc segment, resulting in more effective reversal of the compression upon the disc and z-joints. In addition, the software in the DRX program creates an intermittent pulsation distraction, a major key component in restoring discal hydration.
The FDA concluded that the DRX9000 achieves its effects through decompression of the intervertebral discs and facet joints, in effect, unloading excessive pressure. Indeed, vertebral axial decompression fills the gap in treatment between spinal manipulation and disc surgery.
A study by Gose et al.20 from the University of Chicago collected data from twenty-two medical centers for patients who received spinal decompression therapy for low back pain, which was sometimes accompanied by referred leg pain. Only patients who received at least ten sessions and had a diagnosis of herniated disc, degenerative disc, or facet syndrome, which were confirmed by diagnostic imaging, were included in this study; a total of 778 cases. The patients’ quantitative assessments of their own pain, mobility, and ability to carry out the usual ‘activities of daily living was rated successful in 71% of the 778 cases.
An Invitation to You
Indeed, it’s a new era in the treatment of LBP. If you are also committed to the best in evidence-based healthcare for LBP as I am, I urge you to visit my office. Once you see my equipment and meet my staff, you’ll have the confidence to refer your patients for acute or chronic low back pain as well as for the serious whiplash cervical injuries. I guarantee that you will be sent reports on your patients and, if they do not respond to my care, I will either refer them back to you or to a local orthopedist. My goal is to give patients the best of all worlds in health care. Hopefully your goal is the same. Please logon to www.smithspinalcare.com to learn more about my office, my approach, and the DRX9000.
References
1. Chapman-Smith D. (2004) Chiropractic Management for Lumbar Disc Herniation, Sept. vol. 18, no. 5, The Chiropractic Report
2. Boden, S et al. (2003) Emerging techniques for treatment of degenerative lumbar disc disease, Spine 28:524-525.
3. Waddell G. Low back pain: a twentieth century health care enigma. Spine 1996 Dec 15; 21 (24):2820-5
4. Bernstein, E, Carey TS, Garrett JM (2004) The use of muscle relaxant medications in acute low back pain. Spine 2004:29(12):1346-51.
5. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70.
6. Bigos S. et al. US Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline, Number 14: Acute Low Back Problems in Adults AHCPR Publication No. 95- 0642, December 1994.
7. Weber H (1994) The natural history of disc herniation and the influence of intervention, Spine 19:2234-2238.
8. Saal J (1996) Natural history and nonoperative treatment of lumbar disc herniation, Spine 21:2S-9S.
9. Postacchini F (1996) Results of surgery compared with conservative management for lumbar disc herniations, Spine 21:1383-1387.
10. Quon JA, Cassidy JD et al. (1989) Lumbar intervertebral disc herniation: treatment by rotational manipulation, J Manipulative Physiol Ther 12(3)220-227.
11. Bourdillon JF, Day EA (1987) Spinal manipulation, 4th edition, William Heineman medical books, London, 216-217.
12. Lewit K (1985) Manipulative therapy and rehabilitation of the locomotor system; Butterworths, London and Boston, 178.
13. Chrisman OD et al. (1964) A study of the results following rotary manipulation in the lumbar intervertebral disc syndrome, J Bone Joint Surg 46A:517-524.
14. Henderson RS (1952) The treatment of lumbar intervertebral disk protrusion: an assessment of conservative measures, Br. Med J 2:597-598.
15. Mensor MD (1955) Non-operative treatment, including manipulation, for lumbar intervertebral disc syndrome, J Bone Joint Surg 37A:926-935.
16. Kuo PP, Loh Z (1987) Treatment of lumbar intervertebral disc protrusions by manipulation, Clin Orthop 215:47-55.
17. d’Ornano J, Conrozier T et al. (1990) Effets de manipulations vertebrales sur al hernie discale lombaire, Rev. Med Orthop 19:21-25.
18. Triano J Biomechanics of spinal manipulation. Spine 2001;1:121-30.
19. Shealy, CN, MD, PhD, and Borgmeyer, V RN, MA, Emerging Technologies: Preliminary Findings, Decompression, reduction, and stabilization of the lumbar spine: a cost-effective treatment for lumbosacral pain; AJPM Vol. 7 No. 2 April 1997
20. Gose EE, Naguszewski WK, Naguszewski RK.Vertebral axial decompression therapy for pain associated with herniated or degenerated discs or facet syndrome: an outcome study. Department of Bioengineering, University of Illinois at Chicago, USA. Neurol Res. 1998 Apr;20(3):186-90.
Low back pain is an epidemic that has undergone much scrutiny lately with 17 new international guidelines and 60+ RCTs. Evidence-based medicine now offers a new paradigm for treatment of LBP. Even so, it would be a leap of faith to say that doctors and chiropractors always agree on the best way to treat back pain. Let me share with you comments from the leading spinal experts in this era of EBM for LBP.
“A disease like back pain can have a lot of variability in the ways medical professionals approach patient care,” according to Scott Boden, MD, director of the Emory Orthopaedic and Spine Center in Atlanta. 1 “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders. That leads to some of the [high] costs. The best thing is to have an organized, integrated approach that uses state-of-the-art and cost-effective care.”
The problem for most PCPs is to find the right chiropractor to refer patients according to Dr. Boden. “We screened 50% of the chiropractors in the Atlanta area before we found two who were medically appropriate and similar in approach to how we deal with spine problems.”
Hopefully the Smith Spinal Care Center in Warner Robins will be the appropriate choice when you or your patients seek an effective solution for their back problems. As a nationally-certified spine facility, we follow the latest guidelines to offer a scientific, evidence-based approach to solving this epidemic of LBP.
MRI “False Positive” Imaging
Although the use of MRI scans to detect disk problems has been routine for years, many spine experts now question whether or not these spinal scans are really necessary in light of the ubiquitous nature of disc abnormalities. “The vast majority of people with back pain aren’t candidates for surgery,” according to Dr. Boden. “It should be emphasized that back pain is not necessarily correlated or associated with morphologic or biomechanical changes in the disc.” 2
According to another leading spine researcher, Richard Deyo, MD, MPH, University of Washington Medical School, “In addition, there is evidence of excessive imaging and surgery for low back pain in the United States, and many experts believe the problem has been ‘over-medicalized.’”3
Dr. Deyo also mentioned scans often leads to a “false positive” misdiagnosis. In his article in The New England Journal of Medicine, he also debunks the outdated disk theory:
“Early or frequent use of these tests [CT and MRI] is discouraged, however, because disk and other abnormalities are common among asymptomatic adults. Degenerated, bulging, and herniated disks are frequently incidental findings, even among patients with low back pain, and may be misleading. Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”
Unnecessary Disc Surgery
There is now broad agreement in medical practice that surgery should not generally be considered until there has been a trial of conservative non-surgical care, primarily spinal manipulative therapy. 8,9,10
The AHCPR 23–member panel headed by orthopedist Stanley Bigos, unquestionably the most in-depth meta-analysis of LBP, issued its findings in 1994 and recommended spinal manipulation as a “Proven Treatment” and the preferred initial professional treatment for low back pain. This guideline states:
“This treatment (using the hands to apply force to the back to ‘adjust’ the spine) can be helpful for some people in the first month of low back symptoms. It should only be done by a professional with experience in manipulation.”5
This panel also stated,
“Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.” 4
Muscle Relaxants: Overused, Ineffective
The AHCPR panel determined that muscle relaxants were no more effective than NSAIDs and only “probably” more effective than placebo medications.4 In a recent issue of Spine, researchers found “in patients with severe acute LBP, muscle relaxant use was associated with a statistically significant increase in time to functional recovery. The mean time for patients to return to work was 16.2 days in the placebo group while among patients who used muscle relaxants, average recovery time was twice as long: 32.4 days. Furthermore, in patients with less severe episodes of back pain, there was “no demonstrable effect from muscle relaxant use.”11
Slipped Discs Versus Slipped Joints
Evidence-based care is bringing major changes to the management of patients with low back pain associated with disc herniation. Many physicians understand that back pain alone very rarely requires surgery, but the question concerning LBP with sciatica presents another consideration: can spinal manipulative treatment be as effective as spinal surgery for disc herniation? While traditional medicine may be wary of a non-surgical approach to the management of disc herniation, in fact, the latest studies suggest that, in fact, SMT and spinal axial decompression may be the best methods for the majority of these cases.
The missing link in the treatment of idiopathic LBP may be the overlooked fact that, aside from 23 discs, the spine has 137 joints altogether and the accumulative effect from traumatic injuries compounded by the effects from gravity such as prolonged sitting/standing, improper lifting, and obesity will develop a functional spinal lesion that causes a “segmental buckling effect” according to research by John Triano, DC, PhD, et al. at the Texas Back Institute.11
In this sequential scenario, the overloading of spinal joints causes them to buckle, leading to joint dysfunction that elicits the pain responses—mechanoreceptors in the joint capsules and nociceptors in the soft tissues—causing reflex spasms, disc herniation leading to degeneration, inflammation and, of course, back pain. The bio-mechanical overload on the joints and discs explains the herniation often seen in these cases, but the altered joint mechanics is now believed to be the primary cause of pain and protrusions.
In other words, most LBP may not be caused initially by a slipped disc as much as by slipped joints. This also may explain why a patient doing perfectly well one moment may suddenly experience an excruciating back pain while doing virtually a minor act. Indeed, it’s the proverbial straw that broke the camel’s back.
Many chiropractic and medical researchers consider that the effectiveness of skilled manipulation can primarily be explained as the alleviation of pain from overlying facet joint dysfunction or, in chiropractic parlance, the vertebral subluxation.12,13 ,14,15 Several studies have recently shown that 50-80% of patients with lumbar disc herniation are relieved by side-posture manipulation.16,17,18 ,19
The largest study by Kuo and Loh18 involved a series of 517 patients over an eight-year study period. All had a diagnosis of lumbar disc protrusion and were referred for manipulative therapy. 77% had a favorable response, defined as relief of pain at least to the extent that the patient could perform daily activities.
Spinal Decompression with DRX9000
Certainly not every LBP patient responds to SMT, especially those with failed back surgery syndrome. For those cases, spinal axial decompression therapy (non-surgical, non-manipulative) has also proven very effective in treating disc herniation and degeneration with an 86% success rate according to extensive research by CN Shealy, MD, PhD.20
Vertebral axial decompression is capable of reducing intradiscal pressure to the negative range allowing the disc to be imbibed with nutrients as well as relieving the excessive pressure to allow the disc herniation to be minimized.
A study by Gose et al.21 from the University of Chicago collected data from twenty-two medical centers for patients who received spinal decompression therapy for low back pain, which was sometimes accompanied by referred leg pain. Only patients who received at least ten sessions and had a diagnosis of herniated disc, degenerative disc, or facet syndrome, which were confirmed by diagnostic imaging, were included in this study; a total of 778 cases. The average time between the initial onset of symptoms and the beginning of this therapy was 40 months, and it was four months or more in 83% of the cases. The data contained the patients’ quantitative assessments of their own pain, mobility, and ability to carry out the usual ‘activities of daily living. The treatment was successful in 71% of the 778 cases.
An Invitation to You
If you or your patients seek a non-surgical solution to back pain, my office offers the state of the art equipment. Along with my 25-years experience in SMT, the DRX decompression table, and our spinal rehab equipment, my 4,200 sq.ft. facility brings the best spinal technology to Warner Robins and all of middle Georgia.
If you are also committed to the best in evidence-based healthcare for LBP, I urge you to visit my office. I’m certain you’ll have the confidence to refer your patients for acute or chronic low back pain as well as for the serious whiplash cervical injuries.
References:
1. Trubo, R. Fighting Back When Your Back Aches, WebMD.com, July 19, 2004.
2. Boden, S et al. (2003) Emerging techniques for treatment of degenerative lumbar disc disease, Spine 28:524-525.
3. Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70.
4. Bigos S. et al. US Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline, Number 14: Acute Low Back Problems in Adults AHCPR Publication No. 95-0642, December 1994.
5. Bigos S. et al. AHCPR Publication No. 95-0642, December 1994.
6. Shekelle, PG et al. Congruence between decisions to initiate chiropractic spinal manipulation for low back pain and appropriateness criteria in North America. Ann In Med. 1998;129:9-17.
8. Weber H (1994) The natural history of disc herniation and the influence of intervention, Spine 19:2234-2238.
9. Saal J (1996) Natural history and nonoperative treatment of lumbar disc herniation, Spine 21:2S-9S.
10. Postacchini F (1996) Results of surgery compared with conservative management for lumbar disc herniations, Spine 21:1383-1387.
11. Bernstein E. et al. The use of muscle relaxant medications in acute low back pain. Spine 2004:29(12):1346-51.
11. Triano J Biomechanics of spinal manipulation. Spine 2001;1:121-30.
12. Quon JA, Cassidy JD et al. (1989) Lumbar intervertebral disc herniation: treatment by rotational manipulation, J Manipulative Physiol Ther 12(3)220-227.
13. Bourdillon JF, Day EA (1987) Spinal manipulation, 4th edition, William Heineman medical books, London, 216-217.
14. Lewit K (1985) Manipulative therapy and rehabilitation of the locomotor system; Butterworths, London and Boston, 178.
15. Chrisman OD et al. (1964) A study of the results following rotary manipulation in the lumbar intervertebral disc syndrome, J Bone Joint Surg 46A:517-524.
16. Henderson RS (1952) The treatment of lumbar intervertebral disk protrusion: an assessment of conservative measures, Br. Med J 2:597-598.
17. Mensor MD (1955) Non-operative treatment, including manipulation, for lumbar intervertebral disc syndrome, J Bone Joint Surg 37A:926-935.
18. Kuo PP,Loh Z (1987) Treatment of lumbar intervertebral disc protrusions by manipulation, Clin Orthop 215:47-55.
19. d’Ornano J, Conrozier T et al. (1990) Effets de manipulations vertebrales sur al hernie discale lombaire, Rev. Med Orthop 19:21-25.
20. Shealy, CN, MD, PhD, and Borgmeyer, V RN, MA, Emerging Technologies: Preliminary Findings, Decompression, reduction, and stabilization of the lumbar spine: a cost-effective treatment for lumbosacral pain; AJPM Vol. 7 No. 2 April 1997
21. Gose EE, Naguszewski WK, Naguszewski RK.Vertebral axial decompression therapy for pain associated with herniated or degenerated discs or facet syndrome: an outcome study. Department of Bioengineering, University of Illinois at Chicago, USA. Neurol Res. 1998 Apr;20(3):186-90.