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A Chiropractic Approach to Low Back Pain (1076 words excl. References)

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Introduction:

Low back pain (LBP) is conventionally defined as pain, muscle tension or stiffness localised below the costal margin and above the inferior gluteal folds, with or without associated leg pain. [3]

LBP poses a significant worldwide epidemiologic burden, especially in women, adults and high SDI countries, displaying an escalating trend not expected to reverse soon. [1] Up to 80% individuals will experience an episode at some point throughout the lifetime [2] LBP poses a significant worldwide epidemiologic burden [1]

Low back pain is the #15 worldwide cause of DALY’S (disability-adjusted life years; LBP, low back pain.) [1] Hurwitz et al. Reported in 2015, low back and neck pain were ranked the fourth leading cause of disability-adjusted life years (DALYs) globally, but after ischemic heart disease, cerebrovascular disease, and lower respiratory infection {low back and neck pain DALYs [thousands] [5]

Approximately 60% of people with low back pain also have associated leg pain symptoms. A total of 1907 chiropractors reported treating patients experiencing LBRLP, with 80.9% of them ‘often’ treating LBRLP. [4]

Should I consult a chiropractor for low back pain?

Bussières A et al. says, ‘A multimodal approach including chiropractic treatment, other commonly used active interventions, self-management advice, and exercise is an effective treatment strategy for acute and chronic back pain, with or without leg pain’. [6]

Farabaugh et al. says, ‘The evidence supports that doctors of chiropractic are well suited to diagnose, treat, co-manage, and manage the treatment of patients with low back pain. [7]

Meade T W et al. says, ‘for patients with low back pain in whom manipulation is not contraindicated, chiropractic almost certainly confers worthwhile, long term benefit but with hospital outpatient management. The benefit is seen mainly in those with chronic or severe pain and introducing chiropractic…should be considered. [8]

The percentage of patients with acute low back pain that go on to a
chronic state varies between studies from 2% to 34%. [9]

Early intervention with examination, information, and recommendations to stay active showed significant effects in reducing sick leave for patients with low back pain. [10]

In western countries low back pain is the 3rd biggest cause of time off work. [11]

The human spine.

The human spine is a complex structure. The average weight of the human head is 8-11lb and its centre of gravity is behind the ears. This means the load bearing impact on the posterior neck muscles and spine in general is constant, particularly when we spend so much time in front of computers!  Think of those ball throwing devices we used to toss a ball for our dogs. Imagine a heavier ball on the same device. This requires our spinal muscles to work frantically 24/7 (yep even when we’re asleep) to hold our heads upright and prevent us from nodding forwards.

Eventually though, ligaments deform and stretch along with the muscles and our spines change from a ‘C’ curve to straight to reverse. The further forward our heads the more strain on our spines which leads to the long spinal muscles straining and spinal joints starting to degenerate. This is called osteo-arthritis and can affect the lower neck, mid back and low back. One of the leading causes of low back pain is forward head posture.

So, let me back up for a minute.

When a joint is under excessive load bearing, the body responds by producing bone spurs which is part of osteo-arthritic degeneration. Of course, bone spurs bring their own problems, namely immobility and nerve irritation. Excessive load bearing causes the micro-tears to develop in the discs, muscles, ligaments and joint tissues and all these structures can be pain generated.

Research tells us twisting movements are 2-3x are more likely to injure the low back spinal disc and flexion (forward bending) 2x! [12,13]

So, let’s now move to low back pain. Sitting places more stress on the low back discs than any other position. So sedentary jobs are, therefore, a leading cause of low back problems. Other professions which I consider in the top 5 include roof tilers, brickies, concreters, abattoir workers and plasterers.

From a diagnostic view there are red and yellow flags. Red flags are things like lower limb weakness, numb feet, numb bottom and altered bowel – bladder pattern. A yellow flag might be pain, tingling, local pain etc.

How do chiropractors manage low back pain (best practice)?

Your chiropractor will order a plain film x-ray, however, it may be helpful to refer for CT or MRI to further evaluate the disc and nerves. Rarely, in our practice would we refer to a neuro-surgeon.

The Best practice is not about fixing or curing but more about managing. It is believed there is an as much as 50% incidence of disc bulges or even slight protrusion in the lumbar spine in the general population without any pain.

Charles F. Mahl reported one study demonstrating 20% of individuals with no symptoms under 60 years of age, having MRI evidence of disc herniations and 37% over the age of 65 that are asymptomatic have a disc herniation. He goes on to say the New England Journal of Medicine, Jensen and Modic noted 52% of asymptomatic individuals demonstrated a disc bulge on MRI and 27% demonstrated a disc protrusion. [14]

Chiropractors seek to understand the abnormal load bearing on the spine. This involves assessing both joint mechanics and muscle functioning.

The goal of the chiropractor is to restore as well as possible, normal joint function.

In my opinion this is more about understanding the over-arching strengths and weaknesses of the individual in the context of their mechanical presentation. From this stand-point, rather than focus on a ‘fix or cure’ model, again in my view it is more about a ‘management’ process. This infers a continuum where the chiropractor works with the patient to achieve improving degrees of management over time. Collaboration is about treatment, an appropriate schedule and suitable home-based advice.

I once heard at a clinical back pain conference, exercise and time are more evidence based than just about any therapy! I’m not sure if this is entirely true, however, my clinical experience over 25 years has demonstrated the importance of exercise and when to treat and not to treat to achieve the best results.

Conclusion:

If you are suffering low back pain, I recommend considering chiropractic as one option.

References:

[1] Mattiuzzi et al., Current epidemiology of low back pain received: 23 January 2020. Accepted: 03 April 2020; Published: 25 June 2020. doi: 10.21037/jhmhp-20-17 View this article at: http://dx.doi.org/10.21037/jhmhp-20-17

[2] Ehrlich GE. Low back pain. Bull World Health Organ. 2003;81:671-6.

[3] Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006;332:1430-4.

[4] Fernandez et al., The profile of chiropractors managing patients with low back-related leg pain: analyses of 1907 chiropractors from the ACORN practice-based research network, Chiropr Man Therap. 2019; 27: 19.

Published online 2019, Apr 17. Doi: 10.1186/s12998-019-0239-x, PMCID: PMC6469207

[5] Hurwitz E et al., The Global Spine Care Initiative: a summary of the global burden of low back and neck pain studies, published: 26 February 2018, European Spine Journal volume 27, pages796–801(2018).

[6] Bussières A, et al., Spinal Manipulative Therapy and Other Conservative Treatments for Low Back Pain: A Guideline From the Canadian Chiropractic Guideline Initiative, Journal of Manipulative and Physiological Therapeutics, Volume 41, Issue 4, May 2018, Pages 265-293, https://doi.org/10.1016/j.jmpt.2017.12.004

[7] Farabaugh et al., Clinical Practice Guideline: Chiropractic Care for Low Back Pain, Journal of Manipulative and Physiological Therapeutics

Volume 39, Issue 1, January 2016, Pages 1-22, https://doi.org/10.1016/j.jmpt.2015.10.006.

[8] Meade T W et al., Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment.

British Medical Journal 1990; 300

Doi: https://doi.org/10.1136/bmj.300.6737.1431 (Published 02 June 1990)

[9] Steenstra I, A et al., Prognostic factors for duration of sick leave in patients sick listed with acute low back pain: a systematic review of the literature, BMJ, Vol 62, Issue 12, http://dx.doi.org/10.1136/oem.2004.015842

[10] Molde E et al., Does Early Intervention With a Light Mobilization Program Reduce Long-Term Sick Leave for Low Back Pain? Spine: August 1, 2000 – Volume 25 – Issue 15 – p 1973-1976.

[11] https://www.theaccessgroup.com/blog/causes-of-sickness-absence/#:~:text=1.,calling%20in%20sick%20last%20year.&text=Because%20minor%20illness%20is%20such,its%20impact%20on%20the%20business.

[12] Bogduk, N. (2012). Radiological and Clinical Anatomy of the Lumbar Spine (5th ed.). China: Churchill, Livingstone.

[13] McGlashen K M et al.,  Load displacement behaviour of the human lumbo-sacral joint, J Orthop Res1987;5(4):488-96. doi: 10.1002/jor.1100050404.DOI: 10.1002/jor.1100050404.

[14] Charles F. Mahl, M.D. FACS FICS Medical Director BAC Colonnade 2333 Ponce De Leon Blvd, Suite 302. Coral Gables, Florida 33134 Telephone: 305.332.7234 Toll Free: 844.859.7788 Facsimile: 305.669.0241 Website: www.GenLifeRegenerativeMedicine.com

About the Author:

Dr. Andrew Arnold is a Chiropractor at Cranbourne Family Chiropractic and Wellness Centre.


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