Back Pain: Does Maintenance Care Work?

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.”

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Can Exercise Prevent Low Back Pain?

While it’s not possible to totally prevent low back pain (LBP), individuals who regularly exercise appear to have a reduced risk for LBP. Additionally, fit adults who develop back pain may experience it less often, at a reduced intensity, and for a shorter duration than those who lead a more sedentary lifestyle.low backWhich type of exercise is the best? A general rule is to keep trying different activities, starting with those MOST appealing to you. After all, you should enjoy exercise, so start with your favorites: walking (one of the best), walk/run combinations, running/jogging, bicycling, swimming/water aerobics, yoga, Pilates, core strengthening, balance exercises, tennis, basketball, golfing, etc.

Specific exercises for the low back can be individualized by determining your “position preference”, or the position that feels best to your low back. For example, bend forward as if to touch your toes. How does that feel? Do you feel a good stretch or pain? Does it shoot pain down your leg? If it feels good, then that might be your preferred position and the one to emphasize with exercise. Examples of exercises that fit this scenario include (but are not limited to): posterior pelvic tilts (flatten your low back by rocking your pelvis forward); single and double knee to chest; and bending forward from a chair (as if to touch the floor).

If bending backward feels good (better than flexion and especially if the presence of leg pain lessens or disappears), then “extension-biased” exercises fit that scenario. Examples include standing back extensions (place your hands behind the low back and bend backward); prone “press-ups” (lift the chest off the floor while keeping the pelvis down); and laying back-first over a Bosu- or Gym-ball.

Pelvic dysfunction and core weakness can also increase the risk for LBP. Try these exercises: abdominal crunches (bend one knee, place your hands behind your low back, and raise the breast bone toward the ceiling only a few inches and hold); front and side planks (start from the knees if necessary); supine bridges (supine, knees bent, lift the buttocks off the floor); “bird-dog” (kneel on all fours and raise the opposite leg and arm, keep good form, and alternate); and the “dead-bug” (on your back, bend the hips and knees at 90 degrees with your arms reaching toward the ceiling; slowly lower your right arm and left leg and return them to their starting position; repeat with the other arm/leg).

When lifting, bend the knees and hips but NOT your low back; keep weights close to you and lift with your legs. Don’t attempt lifts that you know are too heavy.

If you have a history of low back pain, research shows that receiving maintenance chiropractic care can help reduce the number of days in which low back pain may hinder your activities.

The Red Flags of Low Back Pain

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.how-to-tell-if-your-back-pain-is-serious

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!

Knee Pain – Do I Need a Replacement?

About a quarter of adults experience frequent knee pain, which results in limited function, reduced mobility, and impaired quality of life. Osteoarthritis (OA) is the most common cause of knee pain in those over 50 years of age, and it is the #1 reason for total knee replacement (TKR). The rate of TKR in the United States and the United Kingdom has increased substantially in recent decades, which many have written off as a consequence of our aging populations. But is that really the case?

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One study reviewed long-term data from the National Health and Nutrition Examination Surveys (NHANES) and the Framingham Osteoarthritis (FOA) study. The research team concluded that advancing age is indeed a factor behind the increase in TKR since the 1970s, but it doesn’t tell the whole story. The researchers also found that obesity is a risk factor for symptomatic osteoarthritis of the knee, and as you know, obesity rates have skyrocketed in the last four decades.

So, what can be done to reduce your risk for a total knee replacement? There isn’t anything you can do about getting older, but there’s a lot you can do to maintain a healthy weight. Begin by switching to a more anti-inflammatory diet such as the Mediterranean diet or the Paleo diet. You don’t have to change everything you eat all at once. Start by eating an extra serving of vegetables and one less serving of processed food a day. As you notice yourself starting to feel better, it will give you the confidence to make further dietary modifications.

Because the primary way for the cartilage in your joints to get nutrients is through movement, you’ll need to become more active. Increase the number of steps you take per day and raise the intensity over time. You should also engage in balance and strength training exercises.

Of course, you’ll also need to ensure your knee isn’t subjected to abnormal movements both above and below that can compromise the tissues that make up the joint. For example, ankle pronation can overload the medial compartment of the knee. Similarly, a problem in the hip, pelvis, or lower back can also place stress on the knee, which can impair its function. That’s why doctors of chiropractic evaluate the whole patient to identify any and all contributing factors to a patient’s chief complaint. Otherwise, the patient may not experience a satisfactory outcome.

 

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

Low Back Pain: Is It Your Feet?

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.

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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.

Low Back Pain: What Can I Do for It?

Back-Pain-PNG-FileLow 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.

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.