Back injury inquiry

[brenno05]

As a newly graduated chiropractor who has spent 5 years at university learning the intricacies of the human body with a large focus on the spine, nervous system and musculoskeletal system and who continually refines my knowledge and skills based on my developing clinical experience and latest evidence this type of attitude frustrates me YRU.
Ive been to many medical conferences and orthopaedic symposiums with GP's, Radiologists and Orthopaedic Surgeons but i don't for one minute claim to be a doctor. I work WITH health professionals in my area, including physiotherapists, exercise physiologists, massage therapists, other chiropractors, naturopaths and kinesiologists I understand my role in the spectrum of health care choices and work within it.
Just keep in mind that not all medical intervention work well, despite double blinded randomised control trials....take VIOXX for instance.
Yes we don't have swags of research papers to back up what we do, but there is a lot out there if you decide to look one day. You have doctors of physical medicine, chiropractors, osteopaths, physiotherapists and even GP's who look at spinal manipulation as a legitimate treatment so would you question these guys as well?

Id be more than happy to have you in at the practice one day to observe what i do on a daily basis and have a chat about why i do things YRU...i find in these situations its a lack of understanding that breeds the animosity

[watermanblue2]

Back to some help with your lower back...I had a lower back injury 15 years ago and have been dealing with it ever since. I have tried almost everything to keep myself in the water. I have been on a very simple stretching and strengthening program for about 4 months and it has been VERY helpful. Here is the web site: http://fixyourownback.com/Videos-of-exe ... elief.html
Good luck!

[yanks r us]

Thanks for the offer, sounds like you really enjoy your work.

OP: I had a look and am I wrong, he said it was the L5, brendo (I assume you mean brenno) said it sounded like sacro-illiac joint. Two different things. Either could be right (and wrong) though. Can I ask how did he diagnose it as being an L5 problem??

Ha, hey buff

Edit: I'd be interested to hear what the evidence for fixing nerve root problems with spinal manip is? Or am I going to get abused again for going against the contrary (in this forum)...

[otway1949]

Edit: I'd be interested to hear what the evidence for fixing nerve root problems with spinal manip is? Or am I going to get abused again for going against the contrary (in this forum)...

That's fair question and not one you should abused for certainly not by me, the trouble is that there is peer review of Chiropractic papers, citations and their claims, very few are taken up by medical researchers and reviewed without bias.
Ill founded citations from old stock are often dragged forward again and again as evidence against Chiropractic, but little of the newer papers ever see the light of day beyond Chiropractic.
That is a major publishing fault of Chiropractic.
Unfortunately rehashing old arguments against Chiropractic with stuff that has been discredited even within its own ranks does no credit to medical ethics in the review of the current practices of Chiropractic.
It's like reviewing current medicine on its practices of 100 years ago.

There is some really interesting writing coming out about the relationships between neuro-anatomy and neuro-physiology and structural relationships within the spine which bears investigation as to how manipulation works with this.

IMO all medical and allied practices should be called to answer about their efficacy and appropriate usage.
Allopathic medicine too has to look at some of its own functions.

Well founded criticism on any science is necessary to step beyond the dogmas of prejudice and will encourage evolution.

and as Captain Caveman said when people go outside their field of expertise to treat, there is a large world of potential risk and unfortunately in any of the professions we have spoken about there are cowboys and they do no good to anyone including their own..

[yanks r us]

Thanks for your opinion Mr Otway.

Definitely agree about problems when people step out of their domain. Although in saying that, some domains are more than questionable.

[Cpt.Caveman]

I think part of the problem with back pain as well, is that its usually next to impossible to diagnose exactly what is causing mechanical/ordinary back-ache. You can get a slightly different opinion from several different practitioners who all try to explain which dysfunction they think is to blame. Unless the symptoms are consistent with proper nerve root compression (approx. 5% of back pain cases), it can be next to impossible to diagnose the cause (even with MRI scans), and discs and sciatica can often be given too much of the blame.

In my opinion its all back to evidence-based practice. If you can't back up your approach with research papers and good quality RCT's then technically you're landing in the "alternative therapies" group, and should be open about that fact so people know what they're paying for/being influenced by.

Anyways, I think manipulative therapies have a very important role to play for certain cases and body problems. In some cases its nearly impossible to correct someones biomechanics without mobilising joints and freeing their range of motion. In other cases, over-reliance on manipulative therapies doesn't treat the cause and only works as a short term fix if the person doesn't practice and solidify better movement in their new range of motion.

Once again, back to practitioners that understand the body well, who stick to evidence-based practice and refer out for complimentary treatments/assessments/opinions when they identify something out of their domain of treatment.

[brenno05]

Well said Cpt.Caveman!

[yanks r us]

I think part of the problem with back pain as well, is that its usually next to impossible to diagnose exactly what is causing mechanical/ordinary back-ache. You can get a slightly different opinion from several different practitioners who all try to explain which dysfunction they think is to blame. Unless the symptoms are consistent with proper nerve root compression (approx. 5% of back pain cases), it can be next to impossible to diagnose the cause (even with MRI scans), and discs and sciatica can often be given too much of the blame.

I don't agree with that. At least in the medical field. Not "all" practitioners give a stab in the dark for the cause of back pain. This is contrary to fields like Chiro who alwaysgive a reason, otherwise what incentive would there be going to one? There are guidelines in place for back pain, needless to say, chiros tend to distance themselves as much as possible from this. I'd love to see a chiro tell a patient to come back in a month or so for unspecific back pain in an otherwise normal and healthy patient far more likely to do unecessary imaging and require them to come back consistently.

[Cpt.Caveman]

I think part of the problem with back pain as well, is that its usually next to impossible to diagnose exactly what is causing mechanical/ordinary back-ache. You can get a slightly different opinion from several different practitioners who all try to explain which dysfunction they think is to blame. Unless the symptoms are consistent with proper nerve root compression (approx. 5% of back pain cases), it can be next to impossible to diagnose the cause (even with MRI scans), and discs and sciatica can often be given too much of the blame.

I don't agree with that. At least in the medical field. Not "all" practitioners give a stab in the dark for the cause of back pain. This is contrary to fields like Chiro who alwaysgive a reason, otherwise what incentive would there be going to one? There are guidelines in place for back pain, needless to say, chiros tend to distance themselves as much as possible from this. I'd love to see a chiro tell a patient to come back in a month or so for unspecific back pain in an otherwise normal and healthy patient far more likely to do unecessary imaging and require them to come back consistently.

I agree, back pain is a funny area. What I meant was that its almost normal for a lot of people to experience chronic mechanical back pain from time-to-time, and all to often in the search for what is causing that pain too many inconclusive labels are used which scare the patient. For example, scans showing degenerative changes, disc space narrowing, herniated discs, spondylolisis, inactive spondylolisthesis, etc. None of which are a diagnosis of mechanical back pain and unless the symptoms are specific to nerve root compression, the diagnosis can still only remain non-specific mechanical back pain. Add this in with the problem that once the back pain is well and truly chronic (4 months plus), not all pain is a sign of damage/injury anymore. All a recipe for patients to think they're fragile, when all they're experiencing is normal chronic mechanical back pain.

In my experience almost all the patients I see with chronic mechanical back pain have some level of biomechanical dysfunction, and treating that dysfunction with active-based therapy almost always improves the symptoms. I never attempt to tell them what I think is causing the pain but I am very open in my discussion about the dysfunctions that I find and how they can cause cumulative or increased stress in the lower back. Rather than trying to diagnose the cause, giving them all of these labels that can make them think they're fragile, I think its far better just to get them into the gold standard treatment straight away and let them develop some confidence in their body again.

[yanks r us]

Yeah for sure. That's why in most circumstances imaging can do more harm than good. If we scanned 100 healthy people a lot would come back with findings, such as disc prolapse etc. So it's obvious that some would erroneously infer that the finding is responsible for the back pain when it probably isn't, and why doing imaging isn't recommended for acute non-spec back pain. No doubt many chiros jump on that oppotunity to the detriment of the patient.

In saying, just to be clear,I think what you do seems great. If not getting results in the short term at worse, it probably minimises the risk of recurrent back pain in the future - among other things.

[yanks r us]

(The following might not make sense because otway deleted his post)

Well that differential is come about through a proper history and examination, by appropriate professionals. (No one has yet to respond to my previous question on how the chiro treating the OP came to his conclusion).

I'd hate to imagine all the needless imaging done by chiros and how much that costs us tax payers each year. Can you give any cases where a chiro has been sued for not imaging?

If you follow the guidelines and use your clinical experience and expertise, you cannot be sued for negligence.

"There are also studies done that show mechanical issues that can be treated Chiropractically, and the citations and papers on these are readily available"

That's quite a vague statement. The question really is, is chiro superior to other methods such as analgesics, simple GP care etc. Facts are facts. Which show it isn't.

Because acute low back pain typically does not have a serious etiology, and because most cases resolve with conservative treatment, immediate imaging is rarely indicated. All major guidelines on the treatment of acute low back pain have similar recommendations regarding imaging.16–20 In the absence of red flag findings, four to six weeks of conservative care is safe and appropriate, and imaging is not indicated. http://www.aafp.org/afp/2007/0415/p1181.html

Diagnostic imaging of the spine has a high rate of abnormal findings in asymptomatic persons. In studies of lumbar spine MRI evaluation in asymptomatic adults, herniated disks were found in 9 to 76 percent of patients, bulging disks in 20 to 81 percent, degenerative disks in 46 to 93 percent, and annular tears in 14 to 56 percent.21 Therefore, imaging should be used in carefully selected patients and interpreted with appropriate clinical correlationhttp://www.aafp.org/afp/2007/0415/p1181.html

[brenno05]

http://www.nytimes.com/2011/10/29/healt ... d=fb-share

[yanks r us]

Wow, ~$1,700 for an MRI, what a rip

[brenno05]

In a recent study, “Manipulation or Microdisketomy for Sciatica? A Prospective Randomized Clinical Study,” (Journal of Manipulative and Physiological Therapeutics, October 2010, Vol. 33 Iss. 8, p: 576-584), researchers concluded that spinal manipulation was just as effective as microdiskectomy for patients struggling with sciatica secondary to lumbar disk herniation (LDH). The patient population studied included people experiencing chronic sciatica (symptoms greater than six months) that had failed traditional, medical management. Overall, 60 percent of patients who received spinal manipulation benefited to the same degree as those who underwent surgery.

“Sciatica is a serious spinal condition that causes pain, numbness, or weakness in one or both legs. Many times when symptoms become debilitating and without further help, surgery is prescribed to alleviate discomfort. But surgery is not without financial and physical drawbacks.”

“To our knowledge, this is the first, randomized trial that directly compared spinal manipulation, which in this study was delivered by a doctor of chiropractic, and back surgery, two popular treatment choices for this prevalent health condition,” says Dr. Gordon McMorland, who co-authored the paper with neurosurgeons Steve Casha, MD, PhD, FRCSC, Stephan J. du Plessis, MD, and R. John Hubert, MD, PhD, FRCSC, FACS. “Sciatica is a serious spinal condition that causes pain, numbness, or weakness in one or both legs. Many times when symptoms become debilitating and without further help, surgery is prescribed to alleviate discomfort. But surgery is not without financial and physical drawbacks.”

According to the study, “Outpatient Lumbar Microdiscectomy: A Prospective Study in 122 Patients”, more than 200,000 microdiskectomies are performed annually in the United States, at a direct cost of $5 billion, or $25,000 per procedure. In this year-long study, consenting participants were chosen randomly to receive either an average of 21 chiropractic sessions over a year or a single microdiskectomy, both with the additional integration of six supervised active rehabilitation sessions and a patient education program. If cost is assumed at $100 per chiropractic visit, there is a direct, total savings of $22,900 per manipulation patient. System-wide, this could save $2.75 billion dollars annually.

“After a year, no significant complications were seen in either treatment group, and the 60 percent patients who benefitted from spinal manipulation improved to the same degree as their surgical counterparts,” says Dr. McMorland, who also points out that, “The 40 percent of patients who were not helped by manipulation did receive subsequent surgical intervention. These patients benefitted to the same degree as those that underwent surgery initially, suggesting there was no detrimental effect caused by delaying their surgical treatment.”

“Our research supports spinal manipulation performed by a doctor of chiropractic is a valuable and safe treatment option for those experiencing symptomatic LDH, failing traditional medical management. These individuals should consider spinal manipulation as a primary treatment, followed by surgery if unsuccessful.”

McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33(8), 576-584

[Cpt.Caveman]

Sciatica is another condition entirely however, rather than mechanical back pain referring down one leg. Now we're talking about proper nerve root compression and in rarer cases piriformis syndrome impingement. Last study I read found proper nerve root compression to be implicated in only around 5% of back pain cases. That is a very physical problem and there are limited conservative approaches available, particularly if several modes of treatment are not making any difference and the symptoms are either permanent or not improving. It becomes even more crucial to get medical advice quickly if you're experiencing permanent motor or sensory loss.

Thats different again to mechanical back pain or the disc and surrounding tissues being the pain generators however. If thats the case we're back to the grey area of mechanical or non-specific low back pain, and many different theoretical biomechanical dysfunctions which can be to blame, often all at once in the one patient.


On the topic of MRI's, I'd avoid the racket box if I can, purely due to the ringing in my ears the next day! Surely someone will develop a more hearing friendly scanning tool soon?