Low Back Pain: Spinal Manipulation vs. NSAIDs

lbpLow 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 on 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.

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How Do MDs View Chiropractic?

In the mid-1980s, a political event spurred a change regarding the medical community’s outward disrespect of chiropractors when the AMA (American Medical Association) was sued for anti-trust violations and the chiropractors won!

For the first time, the public, open anti-chiropractic slander that appeared on billboards, in magazine articles, and in TV/radio advertisements against the chiropractic profession was prohibited.

In fact, prior to this, it was against the AMA by-laws for a Medical Doctor (MD) to publicly socialize with a chiropractor! This all seems pretty extreme but was truly occurring prior to the mid-1980s… BUT NOT ANYMORE!

In 1994, the United Kingdom and the United States almost simultaneously published official guidelines for the treatment of acute low back pain.

BOTH DOCUMENTS REPORTED THE USE OF SPINAL MANIPULATION, A PRIMARY FORM OF CHIROPRACTIC TREATMENT, AS A FIRST CHOICE IN THE TREATMENT FOR ACUTE LOW BACK PAIN.

Now, for the first time, a non-chiropractic group had recommended chiropractic based on researched data that overwhelmingly supported spinal manipulation as an effective, safe, and less expensive form of care when compared to all the other treatment approaches that the healthcare consumer can choose from.

Research has continued to pour in and recently, similar recommendations were made in the treatment of chronic low back pain. Also, when reviewing the research pool, continued support of the 1994 guidelines for acute low back pain was again found to be valid with little change required.back-pain-lg[1]

According to the published guidelines, ALL patients with acute AND chronic low back pain should see chiropractors FIRST.

If this guideline was followed by everyone, there would be such a shortage of chiropractors, it would become one of the most desirable professions to seek vocationally.

Unfortunately, many MDs do not know enough about chiropractic to strongly recommend it to their inquiring patients. That is why our office goes out of its way to educate MDs in our community about the benefits of Chiropractic care.

Also, some programs at medical schools are now including “alternative medicine” courses in the curriculum of the undergraduate MD programs and, rotations in alternative or complimentary health services currently offered at some university / hospital settings as a post-graduate option.

This is reflected by an increasing population of MDs who actively seek out chiropractors to work with when their patients present with conditions like acute or chronic low back pain, neck pain, and/or headaches.

The MD/DC relationship is truly improving as noted by the inclusion of chiropractic into hospital programs, integration into the military bases and VA hospitals, routine coverage by most insurance companies, etc.

So rest assured, you’ve made a smart decision to choose Chiropractic care.

The Many Functions of Your Nervous System

Every movement, smell, taste, touch, sound, thought, and dream has its origin in the nervous system.

Every function of your body, both voluntarily and involuntarily is controlled, at least in part, by your nervous system.

To better understand how the nervous system works, it is necessary to discuss what makes up the nervous system.

The Nervous system is made up of two primary systems: the central nervous systemlabeled-nervous-system-diagram-nervous-system-diagram-labeled-central-nervous-system-diagram and the peripheral nervous system.

The central nervous system (CNS) is made of the brain and spinal cord, while the peripheral nervous system (PNS) is comprised of nerves such as those in our arms, legs, and torso that deliver information back to the CNS for processing.

Many of the functions of the PNS are voluntary—that is, we can control actions like reaching for plate, swinging a golf club, or swimming.

Other actions are involuntary like the beating of the heart, breathing rates during exercise, digesting food, regulating our blood sugar, metabolism, and so on.

Many of the automatic involuntary functions are controlled by a subcategory of the PNS called the autonomic nervous system (ANS) which has two components: the sympathetic and parasympathetic nervous systems.

There is always activity in the sympathetic nervous system operating at a basal level called “sympathetic tone” and its activity increases at times of stress (producing a “fight-or-flight” response).

The parasympathetic nervous system basically does the opposite of the sympathetic nervous system.

When the heart rate increases (sympathetic response), the parasympathetic nervous system slows it down. Just as the “fight-or-flight” response relates to the sympathetic NS, a “rest and digest” function describes the parasympathetic NS.

Hence, the autonomic nervous system (ANS) is made up of nerves that innervate cardiac muscle, smooth muscle, and glandular tissue.

From a functional perspective, think of the nervous system as a highway with information being transmitted to and from different locations in the body.

The roads or pathways bring information to the CNS (brain/spinal cord) and are called sensory nerves (afferent).

Consider what happens when you touch a hot stove…

In this example, your hand is quickly pulled away from the stove. To accomplish this, there are nerve fibers that connect or bridge between the afferent (sensory) and efferent (motor) nerves called interneurons.

To break this down even further, under a microscope, the space or junction between two neurons/nerves is called a synapse, which is a very narrow gap where chemicals called neurotransmitters allow an impulse to pass through the gap so an impulse can travel onto another “road” (nerve) to bring information to and from the CNS. Therefore, each synapse is like a ferry boat (chemicals) carrying a car (the impulse) across the gap to the next road in route to the brain and/or spinal cord. This gets further complicated as there are many different chemicals (“ferry boats”) called neurotransmitters that result in different types of responses. These responses are broadly classified into either those that excite or inhibit and result in an action that is incredibly fast, which is often needed to avoid injury or death. The example of touching the stove clearly describes the quick reaction that results from the combined chemical and electrical signaling that takes place. If these chemicals get out of balance, different reactions can occur and many of the medications used in treating depression, bipolar disorder, schizophrenia and other psychological conditions exert their effects directly on these neurotransmitters (such as serotonin).

So as you can see, the nervous system is very complex and yet, very balanced allowing us to function and perform in an automatic, coordinated way, so that most of the time, we don’t have to think about what we are doing to a point of exhaustion.

Many things can negatively affect the functions of the nervous system such as trauma/injury, lack of sleep, stress, chemical abuse (alcohol, cocaine, heroin, etc.), and diet.

Chiropractic focuses much attention on balancing these functions through manipulation of the spine, which has both local and more distant effects through “somatovisceral” and “somatic” responses, thus affecting both voluntary and involuntary functions.

Management of sleep, stress, diet, exercise, and other aspects of life are important in maintaining a healthy lifestyle and quality of life.

Much of this information was obtained from the following URL (check it out!): http://en.wikipedia.org/wiki/Nervous_system#Nervous_system_in_humans. This site includes many pictures of the CNS and PNS as well as a description of all the components that make up the nervous system.

Can Chiropractic Prevent Some Types of Arthritis?

This question is asked frequently by patients visiting chiropractors.article-009-arthritis

To answer this question, let’s first talk about, “what is arthritis?”

The word “arthritis” is derived from “arth-” meaning “joint” and “-itis” meaning “inflammation.”

Hence, arthritis is basically swelling in the joint.

Many types of arthritis have been identified—in fact, over 100!

Some types of arthritis are primary (not caused by anything that can be identified), while others are secondary to a disease or other condition.

The nine most common primary forms of arthritis are: osteoarthritis, rheumatoid arthritis, septic arthritis, gout, pseudogout, juvenile idiopathic arthritis, Still’s disease, and ankylosing spondylitis.

The most common type that virtually affects everyone sooner or later is osteoarthritis. This is basically the wearing out of the joint, which usually seen in the older person but can be found at any age after trauma or injury occurred or after an infection in the joint.

The next most common is rheumatoid arthritis, which is an autoimmune disease where the person’s antibodies attack the joint (and possibly other tissues as well). This can occur at a young, middle, or older age whenever the body is triggered to produce the joint attacking antibodies. Crystals deposited in joints can injury the cartilage surface of which the most common is gout—often attacking the base joint of the big toe, and pseudogout.

SO NOW THE QUESTION…
CAN CHIROPRACTIC PREVENT
SOME FORMS OF ARTHRITIS?

The answer is yes…. sometimes. For example, when a spinal joint is fixated, stuck, or subluxated, the normal biomechanics of the spine are altered because of the faulty movement between the vertebrae.

Restoring movement can restore proper function so excess forces are not exerted on the adjacent levels.

A good example of this is when 2 or 3 vertebrae are fused together (surgical or congenital), the levels above and below the fusion have to work harder for the spine to move and function and tend to become osteoarthritic sooner than the other non-fused levels.

From a more broad approach, lifestyle changes including exercise, weight management, the use of a brace or splint, and certain medications and dietary supplements can be helpful as well.

Exercise, in particular, can have significant benefits to the joint surface in both pain relief and slowing down or even stopping the degenerative process (osteoarthritis).

Diet emphasizing an anti-inflammatory approach includes the paleodiet or caveman diet where grains/glutens are avoided and lean meats, fruits, and vegetables are emphasized (see http://www.paleodiet.com/ and http://www.deflame.com/).

Chiropractic Care for Children

Chiropractic techniques are not limited to any particular group. Doctors of chiropractic see patients of all ages, sizes, genders, ethnicities, and so on. So, is the care of children “different” than chiropractic care applied to adults? If so, how?

There are studies that have reviewed the treatment of musculoskeletal (MSK) conditions (like low back pain), non-MSK conditions such as asthma, and chiropractic care of infants, adolescents, and teenagers for a variety of conditions. The management techniques utilized by chiropractors for children vary across the profession, but typically, they are modified methods of those applied to adult patients. When one thinks of “chiropractic care,” the immediate image is that of spinal manipulation where a high-velocity, low-amplitude “thrust” is made and joint cavitation occurs (the release of gas creating a cracking sound similar to knuckle cracking).

Chiropractic treatment can also include dietary advice, nutritional or herbal supplement recommendations, posture correction, exercise training, and the use of physiological therapeutic modalities (like electric stim, light, ice, heat, traction, ultrasound, and more). Behavioral counseling may be included, depending on the patient’s condition and the individual training the chiropractor has focused on, especially on a post-graduate level. Chiropractors, like many healthcare providers, have post-graduate board certification options, of which pediatrics is one of many. Looking at research for children and chiropractic, here is what the current literature base supports:

landerchiropracticforchildren1. Pediatric care: There is evidence that chiropractic methods, when properly modified and applied, are safe. However, more research is needed to determine what the current practice model should be for this patient group.

2. Children & adolescents: There is currently research support for treatment of this patient population for some MSK conditions, particularly low back pain. Again, additional, high-quality studies are needed to further support this category.

3. Non-musculoskeletal care (children & adolescents): A call for more research is a common recurring theme for the management of non-MSK conditions among children and teens. There are several case studies (and small-scale studies, in some instances) for conditions such as colic, otitis media, asthma, nocturnal enuresis (bed wetting), and attention deficit hyperactivity disorder, but all require additional high-quality studies before firm conclusions can be made. However, it has been recommended that a chiropractor may play a role on the pediatric healthcare team and it’s been suggested that it is appropriate to utilize a four to six treatment “trial” to determine effectiveness of care for a colicky infant where all other serious diagnoses have been excluded. Similarly, in cases of enuresis and asthma, chiropractic may have a role on the management team.

4. ADHD in children and adolescents: One focused systematic review reported the need for more high-quality research in this area before conclusions can be made either for or against the utilization of chiropractic care for ADHD.

5. Possible adverse effects: In review of (again) limited studies in this area, chiropractic care appears to have little negative issues associated with it. Serious side effects are reported as “rare.”

Bottom line: Though more research is needed, in the absence of underlying pathology, chiropractic care may be considered as part of the pediatric management team for a four to six visit trial to determine treatment effectiveness.

Manipulation vs. Other Treatments?

Mechanical neck pain affects an estimated 70% of people at some point in life. Because many different treatment approaches are available for neck pain, it can be very difficult for those suffering from neck pain to know which treatment approach(es) to choose. Research on this topic has revealed some very interesting information that places chiropractic and spinal manipulation in a VERY STRONG POSITION—in fact, at the TOP OF THE HEAP!

neck

One such study looked at benefits of spinal manipulative therapy (SMT) in patients with acute and subacute neck pain. This study compared three study groups:

  1.  SMT only
  2.  medication only
  3.  home exercise and advice (HEA)

This study randomized 272 neck pain patients suffering from neck pain for 2 to 12 weeks into a twelve-week treatment period using 1 of the 3 treatment approaches tracking the results with the participant-rated pain as the primary treatment outcome measure. Secondary outcome data was obtained from other approaches. The results showed that the group treated with SMT, “…had a statistically significant advantage over medication after 8, 12, 26 and 52 weeks. HEA also had a statistical advantage over medication. Lastly, similar benefits were calculated between the SMT and exercise group. The conclusions support SMT and exercise/advise to be the choice over medication for acute and subacute neck pain patients. Regarding exercise, a similar study showed that “high-dosed supervised strengthening exercise” with and without SMT, was superior to a “low dose home mobilization exercise and advice group at 4, 12, 26, and 52 weeks.”

Regarding chronic neck pain patients (that means pain that has been present for greater than 3 months), another study evaluated the changes that occurred in 191 patients. These patients were randomly assigned to 1 of 3 treatment groups for eleven weeks and evaluated 3, 6, 12, & 24 months after treatment. The 3 treatment options included: 1. Spinal manipulative therapy (SMT) only; 2. SMT with low-tech neck exercises; or 3. a form of exercise using a MedX rehab machine. The results show the highest level of patient satisfaction was found in the 2nd group (SMT with low-tech exercise), suggesting that when individuals present for treatment, spinal manipulation with low-tech exercises results in the most satisfied patient. These findings are important as this study evaluated the LONG-TERM benefits among patients who have had neck pain for a long time (i.e., “chronic”), where as most studies only look at the short-term benefits.

Similar conclusions were reported from perhaps the largest scale study on neck pain based on research from 1980 to 2006 on the use, effectiveness, and safety of non-invasive treatment approaches for neck pain and associated disorders. This review that looked at over 350 published articles found manual therapy (manipulation and mobilization) and supervised exercise to again, SHINE when compared with other treatment options.

What is important is that ALL these studies support what chiropractors do: manipulate the neck and give supervised exercises! So, what are you waiting for? SPREAD THE WORD to everyone that you know who has neck pain—CHIROPRACTIC MAY BE THE BEST CHOICE!!!

Chiropractic Education

Many people seem surprised to find out that the chiropractic education process is so extensive.

We usually reply, “…whether you’re planning to become a chiropractor, medical doctor, or dentist, it takes four years of college followed by and additional 4-5 years of additional education (med school, dental school, chiropractic college) simply because there is that much to learn about the body to become a competent healthcare provider.”

Hence, depending on the area of interest a person has in the healthcare industry, it takes a similar amount of time to complete the educational program.

degrees-diploma_600x315

DID YOU KNOW…

The initial step is completing a typical “pre-med” undergraduate or college degree.

Courses including biology, inorganic and organic chemistry, physics, psychology, various science labs, as well as all the liberal art requirements needed to graduate are included in the undergraduate education process.

Many states require four years of college in addition to four to five academic years of chiropractic education to practice in their particular state. (The requirements are similar in other countries in which chiropractic is a licensed profession.)

The format for chiropractic universities is similar to that of most healthcare disciplines.

The basic sciences are covered in the first half of the educational process after which time successful completion of the National Boards Part I examination is required to move into the second half: the clinical sciences.

From there, internships, residency programs, preceptorship programs become available to the chiropractic student.

Once graduated, residence programs including (but not limited to) orthopedics, neurology, pediatrics, radiology, sports medicine, rehabilitation, internal medicine, and others are also available, as are various masters and doctorate-level programs in specialty areas.

The following chart shows the similarities between three healthcare delivery approaches, DC, MD, and DPT (doctor of physiotherapy).

Curriculum Requirements for the Doctor of Chiropractic degree (DC) in comparison to the Doctor of Medicine degree (MD) and the Doctor of Physical Therapy degree (DPT):chiropractic education

*Does not include hours attributed to post-graduation residency programs.

AS YOU CAN SEE, THE ACTUAL NUMBER OF AVERAGE CLASSROOM AND CLINICAL STUDY HOURS PRIOR TO GRADUATION IS EVEN HIGHER FOR CHIROPRACTIC COMPARED TO THE MD AND DPT CURRICULUM.

It should be noted that this does not include additional educational training associated with residency programs, which are available in the three disciplines compared here.

At one of the chiropractic colleges, the academic core program or Clinical Practice Curriculum consists of 308 credit hours of course study and includes 4,620 contact hours of lecture, laboratory, and clinical education.

There are 10 trimesters of education arranged in a prerequisite sequence.

The degree of Doctor of Chiropractic (D.C.) is awarded upon successful completion of the required course of study.

The academic program may be completed in three and one-third calendar years of continuous residency. Graduation, however, is contingent upon completion of the program in accordance with the standards of the college, which meet or exceed those of its accrediting agencies.

In addition to courses included in the core curriculum, a variety of procedure electives are available to the students. These electives are designed to complement the study of adjustive procedures included and facilitate investigation of specialized techniques.

Doctors of chiropractic are committed to providing the highest quality care available to their patients. They coordinate care with other doctors, when appropriate, in an effort to help their patients in the most efficient, economic, and evidence-based approach possible.