An Open Letter to our Medical friends.

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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.

 

References
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.
4. Joint Commission Online. Revision to Pain Management Standards. http://www.jointcommission.org/assets/1/23/jconline_november_12_14.pdf
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

Trigger points and headaches

One of the most common sources of headache pain is trigger points in the neck muscles. These muscles are often overloaded from poor posture such as sitting in front of a computer or looking down at you phone for long periods of time. Trigger points that form in the upper traps are the most common trigger points in the body. They refer pain up the neck, behind the ear into the temple. The suboccipital muscles refer pain deep into the skull behind the eye. Sternocleidomastoid trigger points will refer pain to the top of the head and around the orbit of the eye. Trigger points need to be manually released to be resolved.

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Planter fascitis and trigger points

Planter fascitis is a painful condition affecting the bottoms of the feet. It involves inflammation and tightness of the planter fascia, which is a tough layer of connective tissue on the bottoms of the feet. Trigger points in the calf and foot muscles are a leading cause of planter fascitis. These points not only cause the muscle to become tight which in turn causes the fascia to be tight, but the trigger point pain referral patterns of these muscle will cause pain to be felt in the bottoms of the feet and heal. These causes are often overlooked leading to ineffective treatment and prolonged suffering.

Myofascial pain syndrome

Myofascial pain syndrome is caused by a stimulus, such as muscle tightness, that sets off trigger points in your muscles. Factors that may increase your risk of muscle

trigger points include:

  • Muscle injury. An acute muscle injury or continual muscle stress may lead to the development of trigger points. For example, a spot within or near a strained muscle may become a trigger point. Repetitive motions and poor posture also may increase your risk.
  • Stress and anxiety. People who frequently experience stress and anxiety may be more likely to develop trigger points in their muscles. One theory holds that these people may be more likely to clench their muscles, a form of repeated strain that leaves muscles susceptible to trigger point

What is myofascial pain syndrome?

Myofascial pain syndrome is a chronic pain disorder. In this condition, pressure on sensitive points in your muscles (trigger points) causes pain in the muscle and sometimes in seemingly unrelated parts of your body. This is called referred pain.

This syndrome typically occurs after a muscle has been contracted repetitively. This can be caused by repetitive motions used in jobs or hobbies or by stress-related muscle tension.

Kids and Sports…….

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Some very interesting information from an article by our friends at physiology-pedia.com:

In the United Kingdom there are a large number of children and adolescents who are participating in sport. The government is currently spending over £450 million on improving the quality of the Physical Education and sport activities that pupils are offered [1]  leading to high numbers of participants in sport, not only inside of school but outside as well, 96.7% of children aged 11-16 and 84.1% of children aged 5-10 participated in sport outside of school [2].
The young person with athletic potential is likely to have enhanced physiological and physical attributes compared to their peers [3]and can therefore be defined as a young athlete.
Low back pain (LBP) occurs in approximately 10% to 15% of young athletes[4] . Schmidt et al (2014) found that competitive adolescent athletes compared to aged matched individuals have increased prevalence of back pain[5].
LBP  is defined as pain localised between the 12th rib and inferior gluteal folds, occuring with or without leg pain [6].

There are significant differences between the nature of LBP in adults and young athletes [7]. The most common causes of LBP in young athletes are spondylolysis, spondylolisthesis, hyperlordosis syndrome (posterior element overuse syndrome) and discogenic pain[7].
The growing spine introduces certain variables that predisposes the back of the young to specific injuries such as pars interarticularis injury; reported to occur in up to 47% of young athletes [7].
It is of great importance for an athlete with persisting symptoms to undergo a thorough assessment [8].

The impact of the structural problems is considered alongside other aspects such as psychological, social and cultural issues [9]. This approach facilitates compliance with the rehabilitation process and promotes recovery [9], as there is evidence showing athletes with a prior back injury are 3 times more likely to develop LBP [10].

 

Young athletes are not immune to the injuries and conditions that plague adult athletes and need to be assessed and treated just as adults do. While the methods and techniques may vary depending on the age of the child, we need to be sure that we avoid the old tropes of “no pain, no gain” and “you’re a kid, you can’t be hurt”.

 

References
  1. Jump up Department for Culture, Media and Sport, Department for Education. Getting more people playing sport, February 2013.
  2. Jump up Department for Culture Media and Sport. Taking Part 13/14 Annual Child Report. Statistic Release September 2014.
  3. Jump up to: 3.0 3.1 3.2 Armstrong N, Van Mechelen W. Paediatric Exercise Science and Medicine. Oxford University Press, 2008
  4. Jump up d’Hemecourt PA, Gerbino PG, Micheli LJ. Back injuries in the young athlete.Clin Sports Med. 2000 Oct;19(4):663-79.
  5. Jump up to: 5.0 5.1 5.2 Schmidt CP, Zwingenberger S, Walther A, Reuter U, Kasten P, Seifert J, Günther KP, Stiehler M. Prevalence of low back pain in adolescent athletes – an epidemiological investigation. Int J Sports Med. 2014; 35(8):684-9
  6. Jump up Krismer M, van Tulder M. Strategies for prevention and management of musculoskeletal conditions. Low back pain (non-specific). Best Pract Res Clin Rheumatol. 2007; Feb;21(1):77-91.
  7. Jump up to: 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 Micheli LJ, WoodR. Back pain in young adults. Significant differences from adults in causes and patterns. Paediatric and Adolescent Medicine1995;Vol 149
  8. Jump up to: 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 Standaert C. Low Back Pain in the Adolescent Athlete.Phys Med RehabilClin N Am.2008; 19(2):287-304
  9. Jump up to: 9.00 9.01 9.02 9.03 9.04 9.05 9.06 9.07 9.08 9.09 9.10 Purcell L and Micheli L. Low back pain in young athletes. Sports Health. 2009;1(3): 212-222
  10. Jump up Greene HS, Cholewicki J, GallowayMT, Nguyen CV, Radebold A. A history of low back injury is a risk factor for recurrent back injuries in varsity athletes. Am J Sports Med.2001;29(6):795-800.