Back Pain

Do I Need an MRI?

~ Dr. Robert Speirs DC ~ Leave a comment
Low back pain is a very common complaint. In fact, it’s the #1 reason for doctor visits in the United States! The economic burden of LBP on the working class is astronomical. Most people can’t afford to be off work for one day, much less a week, month, or more! Because of the popularity of hospital-based TV dramas over the past two decades, many people think getting an MRI of their back can help their doctor fix their lower back problem. Is this a good idea? Let’s take a look!
Patients will often bring in a CD that has an MRI of their lower back to a doctor of chiropractic and ask the ultimate question, “….can you fix me?” Or, worse, “…I think I need surgery.” Sure, it’s quite amazing how an MRI can “slice” through the spine and show bone, soft tissues, disks, muscles, nerves, the spinal cord, and more! Since the low back bears approximately 2/3 of our body’s weight, you can frequently find MANY ABNORMALITIES in a person over 40-50 years old. In fact, it would be quite odd NOT to see things like disk degeneration, disk bulges, joint arthritis, spur formation, etc.!
Hence, the “downside” of having ALL this information is the struggle to determine which finding on the MRI has clinical significance. In other words, where is the LBP coming from? Is it that degenerative disk, bulged disk, herniated disk, or the narrowed canal where the nerve travels? Interestingly, in a recent review of more than 3,200 cases of acute low back pain, those who had an MRI scan performed earlier in their care had a WORSE outcome, more surgery, and higher costs compared with those who didn’t succumb to the temptation of requesting an MRI!
This is not to say MRI, CT scans, and x-rays are not important, as they effectively show conditions like subtle fractures and dangerous conditions like cancer. But for LBP, MRI is often misleading. This is because the primary cause of LBP is “functional” NOT “structural,” so it’s EASY to get railroaded into thinking whatever shows up on that MRI has to be the problem.
Here is how we know this, when we take 1,000 people WITHOUT low back pain between ages 30 and 60 (male or female) and perform an MRI on their lower back, we will find up to 53% will have PAINLESS disk bulges in one or more lumbar disks. Moreover, we will find up to 30% will have partial disk herniations, and up to 18% will have an extruded disk (one that has herniated ALL the way out). Yet, these people are PAIN FREE and never knew they had disk “derangement” (since they have no LBP). When combining all of these possible disk problems together, several studies report that between 57% and 64% of the general population has some type of disk problem without ANY BACK PAIN!
Hence, when a patient with a simple sprain/strain and localized LBP presents with an MRI showing a disk problem, it usually ONLY CONFUSES the patient (and frequently the doctor), as that disk problem is usually not the problem causing the pain!  So DON’T have an MRI UNLESS a surgical treatment decision depends on its findings. That is weakness, numbness, and non-resolving LBP in spite of 4-6 weeks of non-surgical care or unless there is weakness in bowel or bladder control. Remember, the majority of back pain sufferers DO NOT need surgery!
We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs.  If you, a friend, or family member requires care for back pain, we would be honored to render our services.

PFPS Cont. You want details?

~ Dr. Robert Speirs DC ~ Leave a comment

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The muscles of the hip provide not only local stability, but also play an important role in spinal and lower extremity functional alignment. (1-4) While weakness in some hip muscles (hip extensors and knee extensors) is well tolerated, weakness or imbalance in others can have a profound effect on gait and biomechanical function throughout the lower half of the body. (5) Weakness of the hip abductors, particularly those that assist with external rotation, has the most significant impact on hip and lower extremity stability. (5,6)

Hip Abduction.gif

The gluteus medius is the principal hip abductor. When the hip is flexed, the muscle also assists the six deep hip external rotators (piriformis, gemelli, obturators, and quadratus femoris). The gluteus medius originates on the ilium just inferior to the iliac crest and inserts on the lateral and superior aspects of the greater trochanter. While the principal declared action of the gluteus medius is hip abduction, clinicians will appreciate its more valuable contribution as a dynamic stabilizer of the hip and pelvis- particularly during single leg stance activities like walking, running, and squatting. The gluteus medius contributes approximately 70% of the abduction force required to maintain pelvic leveling during single leg stance. The remainder comes predominantly from 2 muscles that insert onto the iliotibial band: the tensor fascia lata and upper gluteus maximus.  Hip abductor strength is the single greatest contributor to lower extremity frontal plain alignment during activity. (6)

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Incompetent hip abductors and/or external rotators allows for excessive adduction and internal rotation of the thigh during single leg stance activities. This leads to a cascade of biomechanical problems, including pelvic drop, excessive hip adduction, excessive femoral internal rotation, valgus knee stress, and internal tibial rotation. (1,7-12)

 

References
1. Szu-Ping Lee, Powers C. Description of a Weight-Bearing Method to Assess Hip Abductor and External Rotator Muscle Performance. JOSPT. Volume 43, Issue 6
2. Crossley KM, Zhang WJ, Schache AG, Bryant A, Cowan SM. Performance on the single-leg squat task indicates hip abductor muscle function. Am J Sports Med. 2011;39:866-873.
3. Presswood L, Cronin J, Keogh JWL, Whatman C. Gluteus medius: applied anatomy, dysfunction, assessment, and progressive strengthening. Strength Cond J. 2008;30:41-53.
4. Sled EA, Khoja L, Deluzio KJ, Olney SJ, Culham EG. Effect of a home program of hip abductor ex- ercises on knee joint loading, strength, function, and pain in people with knee osteoarthritis: a clinical trial. Phys Ther. 2010;90:895-904.
5. van der Krogt MM, Delp SL, Schwartz MH How robust is human gait to muscle weakness? Gait Posture. 2012 Feb 29.
6. Laurie Stickler, Margaret Finley, Heather Gulgin Relationship between hip and core strength and frontal plane alignment during a single leg squat Physical Therapy in Sport Available online 2 June 2014
7. Ireland ML, Willson JD, Ballantyne BT, Davis
IM. Hip strength in females with and without patellofemoral pain. J Orthop Sports Phys Ther. 2003;33:671-676.
8. Noehren B, Davis I, Hamill J. ASB clinical biome- chanics award winner 2006: prospective study of the biomechanical factors associated with iliotib- ial band syndrome. Clin Biomech (Bristol, Avon). 2007;22:951-956.
9. Powers CM. The influence of abnormal hip me- chanics on knee injury: a biomechanical perspec- tive. J Orthop Sports Phys Ther. 2010;40:42-51.
10. Powers CM. The influence of altered lower- extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. J Orthop Sports Phys Ther. 2003;33:639-646.
11. Sigward SM, Powers CM. Loading characteristics of females exhibiting excessive valgus moments during cutting. Clin Biomech (Bristol, Avon). 2007;22:827-833
12. Souza RB, Powers CM. Differences in hip kine- matics, muscle strength, and muscle activation between subjects with and without patellofemo- ral pain. J Orthop Sports Phys Ther. 2009;39:12- 19.

What the heck is a trigger point?

~ bryancobb ~ Leave a comment

By Bryan Cobb, Advanced Remedial Massage Therapist

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What is a Trigger Point?

Trigger Points (TP’s) are defined as a “hyper-irritable spot within a taut band of skeletal muscle. The spot is painful on compression and can evoke characteristic referred pain and autonomic phenomena.”1

Put into plain language, a TP is a painful knot in muscle tissue that can refer pain to other areas of the body. You have probably felt the characteristic achy pain and stiffness that TP’s produce, at some time in your life.

TP’s were first brought to the attention of the medical world by Dr. Janet G. Travell. Dr. Travell, physician to President John F. Kennedy, is the acknowledged Mother of Myofascial Trigger Points. In fact, “Trigger Point massage, the most effective modality used by massage therapists for the relief of pain, is based almost entirely on Dr. Travell’s insights.”2 Dr. Travell’s partner in her research was Dr. David G. Simons, a research scientist and aerospace physician.

Trigger Points are very common. In fact, Travell and Simons state that TP’s are responsible for, or associated with, 75% of pain complaints or conditions.1 With this kind of prevalence, it’s no wonder that TP’s are often referred to as the “scourge of mankind”.

Trigger Points can produce a wide variety of pain complaints. Some of the most common are migraine headaches, back pain, and pain and tingling into the extremities. They are usually responsible for most cases of achy deep pain that is hard to localize.

A TP will refer pain in a predictable pattern, based on its location in a given muscle. Also, since these spots are bundles of contracted muscle fibres, they can cause stiffness and a decreased range of motion. Chronic conditions with many TP’s can also cause general fatigue and malaise, as well as muscle weakness.

Trigger Points are remarkably easy to get, but the most common causes are

TP’s (black X) can refer pain to other areas (red)

 

Sudden overload of a muscle

  • Poor posture
  • Chronic frozen posture (e.g., from a desk job), and
  • Repetitive strain

 

Once in place, a TP can remain there for the remainder of your life unless an intervention takes place.

 

Trigger Points Not Well Known

With thousands of people dealing with chronic pain, and with TP’s being responsible for — or associated with — a high percentage of chronic pain, it is very disappointing to find that a large portion of doctors and other health care practitioners don’t know about TP’s and their symptoms.

Scientific research on TP’s dates back to the 1700’s. There are numerous medical texts and papers written on the subject.

But, it still has been largely overlooked by the health care field. This has led to needless frustration and suffering, as well as thousands of lost work hours and a poorer quality of life.

 

How Are Trigger Points Treated?

As nasty and troublesome as TP’s are, the treatment for them is surely straight-forward. A skilled practitioner will assess the individual’s pain complaint to determine the most likely location of the TP’s and then apply one of several therapeutic modalities, the most effective of which is a massage technique called “ischemic compression”.

 

Basically, the therapist will apply a firm, steady pressure to the TP, strong enough to reproduce the symptoms. The pressure will remain until the tissue softens and then the pressure will increase appropriately until the next barrier is felt. This pressure is continued until the referral pain has subsided and the TP is released. (Note: a full release of TP’s could take several sessions.)

 

Other effective modalities include dry needling (needle placed into the belly of the TP) or wet needling (injection into the TP). The use of moist heat and stretching prove effective, as well. The best practitioners for TP release are Massage Therapists, Physiotherapists, and Athletic Therapists. An educated individual can also apply ischemic compression to themselves, but should start out seeing one of the above therapists to become familiar with the modality and how to apply pressure safely.

 

 

 

1 Simons, D.G., Travell, D.G., & Simons, L.S. Travell and Simons’Myofascial Pain and Dysfunction: the Trigger Point Manual.

Vol. 1. 2nd ed. Lippincott, Williams, and Wilkins, 1999.

Why Does My Back Hurt?

~ Dr. Robert Speirs DC ~ Leave a comment
​

It’s been said that if you haven’t had back pain, just wait, because (statistically) some day you will! The following list is a list of “causes” that can be easily “fixed” to reduce your risk for a back pain episode.
1. MATTRESS: Which type of mattress is best? The “short answer”: there is no single mattress (style or type) for all people, primarily due to body type, size, gender, and what “feels good.” TRY laying on a variety of mattresses (for several minutes on your back and sides) and check out the difference between coiled, inner springs, foam (of different densities), air, waterbeds, etc. The thickness of a mattress can vary from 7 to 18 inches (~17-45 cm) deep. Avoid mattresses that feel like you’re sleeping in a hammock! A “good” mattress should maintain your natural spinal curves when lying on your sides or back (avoid stomach sleeping in most cases). Try placing a pillow between the knees and “hug” a pillow when side sleeping, as it can act like a “kick stand” and prevent you from rolling onto your stomach. If your budget is tight, you can “cheat” by placing a piece of plywood between the mattress and box spring as a short-term fix.
2. SHOES: Look at the bottom of your favorite pair of shoes and check out the “wear pattern.” If you have worn out soles or heels, you are way overdue for a new pair or a “re-sole” by your local shoe cobbler! If you work on your feet, then it’s even more important for both managing and preventing LBP!
3. DIET: A poor diet leads to obesity, which is a MAJOR cause of LBP. Consider the Paleo or Mediterranean Diet and STAY AWAY from fast food! Identify the two or three “food abuses” you have embraced and eliminate them – things with empty calories like soda, ice cream, chips… you get the picture! Keeping your BMI (Body Mass Index) between 20 and 25 is the goal! Positive “side-effects” include increased longevity, better overall health, and an improved quality of life!
4. EXERCISE: The most effective self-help approach to LBP management is exercise. Studies show those who exercise regularly hurt less, see doctors less, have a higher quality of life, and just feel better! This dovetails with diet in keeping your weight in check as well. Think of hamstring stretches and core strengthening as important LBP managers – USE PROPER TECHNIQUE AND FORM; YOUR DOCTOR OF CHIROPRACTIC CAN GUIDE YOU IN THIS PROCESS!
5. POSTURE: Another important “self-help” trick of the trade is to avoid sitting slumped over with an extreme forward head carriage positions. Remember that every inch your head pokes forwards places an additional ten pounds (~4.5 kg) of load on your upper back muscles to keep your head upright, and sitting slumped increases the load on your entire back!
We have only scratched the surface of some COMMON causes and/or contributors of back pain. Stay tuned next month as we continue this important conversation!
We realize you have a choice in whom you consider for your health care provision and we sincerely appreciate your trust in choosing our service for those needs.  If you, a friend, or family member requires care for back pain, we would be honored to render our services.

Lumbar Disc Herniation

~ Dr. Christian Manansala D.C. ~ Leave a comment

Great article – thanks to Dr. C. Liebenson for the share.

From the Journal Pain Physician: Incidence of Spontaneous Resorption of
Lumbar Disc Herniation: A Meta-Analysis.

Due to the natural course of lumbar disc herniations (LDH) patients should consider conservative treatment before surgery.

“There is a general consensus among contemporary orthopedists
that, for most patients with LDH, an initial
trial of conservative treatment is preferable to surgical
intervention.”

Source: Zhong, M., et al. (2017). Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician, 20, E45-E52

 

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Exercise and Low Back Pain

~ Dr. Robert Speirs DC ~ Leave a comment

​

Low back pain (LBP) is a very common problem that affects most of us at some point in life and for some, it’s a daily issue. Through education and research, researchers have found low back-specific exercises can not only help get rid of LBP but can also prevent future exacerbations or episodes. Like brushing our teeth, low back exercises are equally important in order to maintain, preserve, and optimize function. But because there are SO MANY exercise options available, it’s hard to know which ones are best, especially for each specific person.
There are different methods for determining the right low back exercises for the patient. One of the most common is to try different exercises to determine individual tolerance, but this is not very specific, as it only determines whether or not the patient is comfortable with an exercise. Another is using physical performance tests (PPTs) that measure the strength and endurance of specific muscle groups, muscle shortness, balance, aerobic capacity, and spinal range of motion.
Physical performance tests are much more specific because they address each patient’s differences. Also, many PPTs include normative data to compare against the patient’s own performance, so repeat use of the abnormal PPTs on a monthly interval can gauge their progress (or the lack thereof), which is motivating to the patient and serves as a great outcome measure!
PPTs are typically done two to four weeks after an initial presentation or at a time when the condition is stable so as not to irritate the condition. Initially, the decision as to which exercise is best is often made by something called “directional preference” or positional bias. This simply means if a patient feels best by bending over, we initially give “flexion-biased” exercises.
Flexion-biased exercises include (partial list): pulling the knees to the chest (single then double), posterior pelvic tilts (flattening the low back into the floor), sitting and/or standing bend overs, hamstring stretches, and more. If a person’s low back feels best bending backwards, their doctor of chiropractic may give extension-biased exercises, which include (partial list): standing back bends, saggy push-ups (prone press-ups), and/or laying on pillows or a gym ball on their back, arching over the ball.
Chiropractors generally add exercises gradually once they’ve determined tolerance and will recheck to make sure the patient is doing them correctly. Studies show that spinal manipulation achieves great short-term results, but when exercise is added to the treatment plan, the patient can achieve a more satisfying long-term result. Unfortunately, other studies have shown that ONLY 4% of patients continue their exercises after pain is satisfactorily managed and they fall back into old habits of not exercising.
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Active Seniors Recover More Easily from Injury.

~ Dr. Robert Speirs DC ~ Leave a comment

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Seniors who regularly exercise appear less likely to suffer a disability, and if they do, they tend to recover quicker. A study that included 1,600 older adults showed that active seniors were 13% less likely to develop a physical disability, and exercisers were one-third more likely to recover from impairment than those who lived a sedentary lifestyle. The findings suggest that it’s never too late to reap the benefits of exercise.

Annals of Internal Medicine, September 2016