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
Carpal tunnel syndrome occurs during compression or irritation of the median nerve at the carpal tunnel on the anterior side of the wrist.
This condition is usually the result of repetitive wrist movement, such as regular and prolonged use of a computer mouse or repetitive movements at work. Carpal tunnel syndrome can also occur as a result of trauma or tendinitis of the flexor muscles of the wrist, or during pregnancy due to nerve compression as a result of swelling in the hands.
It is estimated that about 8% of the adult population is affected, making it a relatively common condition. It is the most common compression neuropathy of the upper limb. Women are twice as affected as men.
The nerves of the hand as well as the tendons of the flexor muscles pass to the anterior aspect of the wrist under the transverse carpal ligament that holds them in place. It is the passage formed by the transverse ligament and the bones of the wrist, called carpal bones, that forms the carpal tunnel. The syndrome usually occurs when, for some reason, the space in the carpal tunnel is reduced and the median nerve is compressed.
In some cases, a dysfunction of the cervical spine can cause symptoms of carpal tunnel syndrome without repetitive wrist extension motion.
Carpal tunnel syndrome can cause, but is not limited to, numbness and tingling in the first three fingers and half of the fourth, as well as atrophy of the hand muscles. During the night, you may experience pain and numbness from prolonged bending of the wrist. Symptoms are also exacerbated during repetitive activities involving wrist movements.
Wrist osteoarthritis is a common health condition characterized by degeneration of cartilage and bone growth.
It is normal to have a mild level of osteoarthritis as you age. However, more pronounced levels of osteoarthritis can lead to pain, swelling and loss of function. Although they can occur without any known particular reason, they most often do as a consequence of trauma such as ligament ruptures or fractures.
Advanced stages of osteoarthritis can affect the ability to perform activities of daily living and sports.
An exacerbation of symptoms generally occurs during a period when the level of physical activity or manual work has been increased drastically.
Wrist osteoarthritis can produce, but is not limited to, local wrist pain, localized swelling and stiffness with wrist movement. A prolonged static position or a sleeping position with direct pressure on the flexed wrist can cause pain.
Each person reacts differently in the presence of osteoarthritis, a progressive condition with no cure. It is possible that the range of motion may decrease over time. An active lifestyle and rehabilitation plan may slow the progression of this condition and make it easier to manage symptoms.
Turf Toe is a sprain of the ligaments and irritation of the joint capsule in the big toe following forced and repeated extension movements.
This condition often occurs in athletes using soft sports shoes on a synthetic turf playing surface and accelerating while running.
The severity of the injury can range from a mild stretching to a complete rupture of the capsule and surrounding ligaments. In some cases, this condition can lead to damage to the muscles that flex the big toe. It may also be associated with a small bone tear at the muscle attachment site of these muscles.
Turf Toe can produce, but is not limited to, pain, joint stiffness, difficulty with impact activities such as running, and sometimes localized big toe edema.
Trochanteric Bursitis: That pain on the outside of your hip…..
Trochanteric bursitis is the irritation of the bursa at the level of the bony prominence of the hip, called the greater trochanter. This bony landmark constitutes an insertion zone for several muscles, including the gluteus medius, the gluteus minimus and the piriformis.
Activities and sports that require repetitive contraction or tensing of these muscles to stabilize the hip can lead to bursa irritation and sometimes inflammation. Trochanteric bursitis can occur following a fall.
The bursa is a thin sac filled with fluid. The trochanteric bursa is located at hip level between the greater trochanter and the tendons of the gluteus medius and minimus muscles and the piriformis. It acts as a lubricant to reduce friction between the muscles and that bony prominence.
Trochanteric bursitis can produce, but is not limited to, pain on the side of the hip, localized edema due to swelling of the bursa, and reduced mobility at the hip.
Trigger finger, also called stenosing tenosynovitis, is a condition in which a finger is locked in a flexed position due to inflammation of the tendon in the sheath that surrounds it, making it difficult for the tendon to glide. It can cause pain over time.
Trigger finger usually occurs on the third or fourth finger as a result of repetitive and excessive hand movements. This condition is found in athletes such as paddlers, tennis players and golfers. Finger trauma can also damage the tendon and cause trigger finger.
This condition is more common in women than in men and often presents in people between the ages of 30 and 50. An inflammatory health condition such as rheumatoid arthritis or diabetes can increase the likelihood of having a trigger finger.
Trigger finger can cause, but is not limited to, pain and swelling in the affected finger. A clicking sound, sometimes painful, can be heard when the finger moves into a flexed or extended position. Symptoms may worsen in the morning upon rising or after a period of inactivity. In more advanced cases, trigger finger can lead to permanent locking of the joint.
A stress fracture is an overuse injury. This type of fracture is defined by a tiny crack in the bone, mainly caused by repetitive forces over time.
This condition affects mainly people that are involved in activities such as walking, running or jumping, where the lower body must absorb the bodyweight. Stress fractures can also develop from the normal use of a bone that’s weakened by a condition such as osteoporosis.
Generally, this injury happens when training intensity and/or volume is increased too quickly with inadequate recovery. Starting a new activity, modifying the training surface and quickly transitioning to a new type of inadequate training shoes are among the risk factors.
A stress fracture can cause but is not limited to, pain and difficulty in weight-bearing activities and localized swelling.
Spondylolisthesis occurs when one vertebra slips out of place. This slight slippage can sometimes cause compression of the nerves and, in some cases, cause tingling, numbness, pain, and even weakness in the legs.
Spondylolisthesis can be the result of a trauma to the spine, a congenital defect or simply be a progression of osteoarthritis. Spondylolisthesis can occur, without apparent cause, as people age. In younger individuals, spondylolisthesis usually occurs as a result of trauma during sports such as gymnastics or football and can cause a fracture in the vertebra.
Each person will react differently to the presence of spondylolisthesis and symptoms can vary considerably. Initially, spondylolisthesis may be present without any noticeable symptoms. When pain is present, it is often felt in the lower back or the buttocks. It can range from mild to severe and can affect daily activities such as walking. Burning and tingling sensations may be felt in the area of the buttocks and legs.
Sitting or leaning forward is often less painful than standing or walking because of the positioning of the spine.
Shoulder osteoarthritis is a condition that can cause stiffness that limits joint range of motion. Over time, movements over the head become limited, generally causing pain and alteration of the normal biomechanics of the shoulder. Your muscles must therefore work harder during movement, generating a feeling of muscle tension.
To date, the exact causes of osteoarthritis have not been fully identified. It is completely normal to have a mild level of osteoarthritis with age. However, the more advanced stages of osteoarthritis can affect the ability to carry out daily activities and sports. An exacerbation of symptoms usually occurs during a period when the level of physical activity has been drastically increased. Direct trauma to the shoulder can also increase the symptoms associated with osteoarthritis.
Each person reacts differently to osteoarthritis. It can produce, but is not limited to, local pain in the front of the shoulder, localized edema and stiffness in certain shoulder movements. Movements over the head and a sleeping position with direct pressure on the shoulder can cause pain.
A labral tear occurs when the labrum, a ring of fibrocartilage used to stabilize the shoulder, tears. There are multiple types of labrum tears but the most common is called a superior labrum anterior and posterior tear (SLAP).
The shoulder is the most mobile joint in the human body, but this mobility also makes it more susceptible to injury.
A labral tear can happen slowly over time or suddenly from a car accident, a fall on an outstretched arm, or a dislocated shoulder. People participating in sports involving repetitive overhead movements, such as throwing athletes, are at greater risk of having a labral tear.
A labral tear can cause, but is not limited to, pain in the front of the shoulder, instability, weakness and a limited active range of motion. The pain is often felt when raising the arm above the head. Clicking or crackling sounds may also be heard during shoulder movement.
It is also possible to feel pain at night, especially when sleeping on the affected shoulder.
Treatment consists of Class IV Laser Therapy, management of any biomechanical stresses in the area and exercise rehabilitation to address any weaknesses that can be putting undue stress on the area.
Shoulder capsulitis happens when the strong connective tissue surrounding the shoulder becomes thick, stiff and inflamed, causing pain and loss of motion in the shoulder in all directions. It is sometimes called adhesive capsulitis or frozen shoulder.
The exact cause of this condition is unknown, but the risk of suffering from it increases following prolonged shoulder immobilization, a stroke or other shoulder conditions.
People over 40 are more prone to developing this condition and women are more commonly affected than men. Diseases such as diabetes, thyroid dysfunction and cardiovascular diseases can increase the risk of suffering from shoulder capsulitis.
Shoulder capsulitis generally causes pain and loss of range of motion in the shoulder. This condition typically develops slowly and can last from a few months to a few years. Symptoms of shoulder capsulitis can generally be categorized into three progressive stages.
In the first one, called the freezing stage, the shoulder becomes progressively stiffer and painful. Pain can be worse at night, especially if you sleep on your affected side.
In the second one, called the frozen stage, stiffness in the shoulder joint is important. Pain may begin to diminish during this stage but the range of motion in the shoulder is very limited and muscles start to lose their strength.
The last stage, called the thawing stage, is the beginning of recovery. There is a reduction in pain and a gradual increase in movement.