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!

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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.

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.

What Type of Doctor Should You See For Acute or Chronic Back Pain?

Have you ever considered which type of doctor is best suited to treat back pain?

Since there are so many treatment options available today, it is quite challenging to make this decision without a little help.

To facilitate, a study looking at this very question compared the effectiveness between medical and chiropractic intervention.

 

Over a four-year time frame, researchers followed 2,780 low back pain patients who were treated using conventional approaches by both MDs (Medical Doctors) and DCs (Doctors of Chiropractic).

Chiropractic treatments included spinal manipulation, physical therapy, an exercise plan, and self-care education.

Medical therapies included prescription drugs, an exercise plan, self-care advice, and about 25% of the patients received physical therapy.

The study focused on present pain severity and functional disability (activity interference) measured by questionnaires mailed to the patients.

The authors of the study reported that chiropractic was favored over medical treatment in the following areas:

  • pain relief in the first 12 months (more evident in the chronic patients);
  • when LBP pain radiated below the knee (more evident in the chronic patients);
  • chronic LBP patients with no leg pain (during the first 3 months)

Similar trends favoring chiropractic were observed in regards to disability but they were of smaller magnitude.

All patient groups saw significant improvement in both pain and disability over the four-year study period.

Acute patients saw the greatest degree of improvement with many achieving symptom relief after three months of care.

This study also found early intervention reduced chronic pain and, at year three, those acute LBP patients who received early intervention reported fewer days of LBP than those who waited longer for treatment.

While both MD and DC treatment approaches helped, it’s quite clear from the information reported that chiropractic should be utilized first.

These findings support the importance of early intervention by chiropractic physicians and make the most sense for those of you struggling with the question of who to see for your LBP.