In the past year, many trusted medical establishments including the FDA (1), CDC (2), Joint Commission (3,4), JAMA (5), and The American College of Physicians/ Annals of Internal Medicine (6) have encouraged medical providers to prescribe spinal manipulation as a first line treatment for acute, subacute, and chronic low back pain.
Most recently, The Lancet echoed that endorsement, and provided a unique perspective:
The reduced emphasis on pharmacological care recommends nonpharmacological care as the first treatment option and reserves pharmacological care for patients for whom nonpharmacological care has not worked. These guidelines endorse the use of exercise and a range of other non- pharmacological therapies, including massage, spinal manipulation, and acupuncture.
Gaps between evidence and practice exist, with limited use of recommended first- line treatments and inappropriately high use of imaging, rest, opioids, spinal injections, and surgery. Doing more of the same will not reduce back-related disability or its long-term consequences. The advances with the greatest potential are arguably those that align practice with the evidence. (7)
Unfortunately, personal experience skews our perception of each other’s merit, i.e., we primarily see each other’s failures since the successes don’t need to seek additional care. Regardless of our professional degree, we all have failed cases mixed into our many clinical successes. We must not lose sight of the evidence supporting each other’s overwhelming proven value for a given diagnosis. If we judge each other by our successes rather than our failures, we will work toward an integrated model where the patient wins. Together, we will help more patients than either working alone.
We are honored for the opportunity to co-manage your patients.
1. FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain. May 2017. Accessed on May 12, 2017
2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain- United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49.
3. The Official Newsletter of The Joint Commission. Joint Commission Enhances Pain Assessment and Management Requirements for Accredited Hospitals. July 2017 Volume 37 Number 7. Ahead of print in 2018 Comprehensive Accreditation Manual for Hospitals.
5. Paige NM, Miake-Lye IM, Booth MS, et al. Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain; Systematic Review and Meta-analysis. JAMA. 2017;317(14):1451-1460.
6. Qaseem A, et al. for the Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514-530.
7. Foster, Nadine EBuchbinder, Rachelle et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet, Published Online March 21, 2018 http://dx.doi.org/10.1016/ S0140-6736(18)30489-6
The scalenes muscles are located in the neck and help with neck movements and inspiration. The anterior scalene runs directly over the brachial plexus that gives nerve and blood supply to the arm. Poor neck and head posture as well as poor breathing mechanics can cause this muscle to become overloaded and develope trigger points. These points will refer pain into the shoulder, arm, and hand. As well as the shoulder blade. When tight, the anterior scalene muscle can put pressure on the brachial plexus causing numbness and tingling felt in the fingers and hand.
The sternocleidomastoid muscle is a thin strap like muscle located on both sides of the front of the neck. It helps with movement and posture of the head and neck. This muscle often becomes shortened and tight in people with poor head forward posture. As a result trigger points can form, and these points can cause pain to refer into the skull, and face around the eye. Trigger points in this muscle can also refer into the inner ear.
The levator scapulae muscle is a thin strap like muscle in your neck. It helps to shrug the shoulders and to side flex the neck. This muscle often becomes over worked when the head is tilted forward, or the shoulders are in an elevated position for prolonged periods of time. When strained trigger points develop. These points will refer pain into the neck and shoulder blade area. Trigger points in the levator scapulae are a main cause of a stiff neck.
The suboccipital muscles are small muscles at the base of the skull. These muscles often get strained by poor neck and head posture. Chronic strain will cause trigger points to form. Trigger points in the suboccipital muscles are major cause of headache pain. These points refer an achy pain deep into the skull being that eye and into the temple.
The trapezius muscle is a large diamond shaped muscle in your back and neck. It helps with shoulder and neck movements. This muscle is often over worked due to poor posture, such as sitting in front of a computer. This muscle is also a common ” stress” muscle where people have their shoulders hunched up to their ears. As a result trigger points in the upper traps are very common. These points refer pain into the temple and behind the ear. Upper trap trigger points are a common cause or headaches.
One of the most common things I treat in my practice is myofascial trigger points in the neck muscles. More often than not these points have been caused to develop due to poor neck and shoulder posture. You know the posture, head forward, shoulders rounded, spine curved. Anyone that has had to sit in front of a computer all day, or in car for a long period of time, or spends a lot of time on their phone has experienced this type of posture. The muscles that are responsible for holding your neck up, and your shoulders back, become fatigued over time causing a chronic overload stress. When this happens trigger points can be formed in the muscle tissue. Trigger points are areas of the muscle that have been jammed in the “on” position. They are Almost like a micro cramp within the muscle. These points are hyper sensitive and cause pain, referred pain, stiffness, and weakness among other symptoms. Trigger points in the neck muscles not only cause neck pain, but also refer pain into the head and face, mimicking headache and migraine type pain.
One of the most common forms of pain I see in my practice is neck and shoulder pain. Many people have jobs that require the muscles of the neck and upper back to work overtime to keep proper neck posture. Sitting in front of a computer all day or being stuck in a car or truck for example will eventually cause these muscles to become strained and develop trigger points. These trigger points will then cause pain, referred pain, stiffness and weakness. Neck and upper back trigger points will refer pain into the neck and head.