Chiropractic vs. Medical Advice, Bed Rest, Natural History/Resolution and Over-the-Counter Drugs for Low Back Pain
By: Mark Studin DC, FASBE(C), DAAPM, DAAMLP
William J. Owens DC, DAAMLP
A report on the scientific literature
Mechanical spine pain is any back pain excluding tumor or infection and has been called low back pain, chronic low back pain, acute low back pain and non-specific low back pain. This is a societal problem and according to Panjabi (2006) “…70-85% of the population in industrialized societies experience low back pain at least once in their lifetime... The total cost of low back pain has been estimated to exceed 50 billion dollars per year in the USA” (p. 668)” Low back pain is historically one of the most prevalent conditions successfully treated in chiropractic offices and still is being questioned in too many medical conversations in spite of the evidence. This lack of referrals to the chiropractic profession by too many medical providers has contributed to perpetuating this reversible epidemic. Day, Yeh Franko, Ramirez, and Krupat (2007) reported that only 26% of fourth year Harvard medical students had a cognitive mastery of physical medicine.
Schmale (2005) reported:
Incoming interns at the University of Pennsylvania took an exam of musculoskeletal aptitude and competence, which was validated by a survey of more than 100 orthopaedic program chairpersons across the country. Eighty-two percent of students tested failed to show basic competency. Perhaps the poor knowledge base resulted from inadequate and disproportionately low numbers of hours devoted to musculoskeletal medicine education during the undergraduate medical school years. Less than 1⁄2 of 122 US medical schools require a preclinical course in musculoskeletal medicine, less than 1⁄4 require a clinical course, and nearly 1⁄2 have no required preclinical or clinical course. In Canadian medical schools, just more than 2% of curricular time is spent on musculoskeletal medicine, despite the fact that approximately 20% of primary care practice is devoted to the care of patients with musculoskeletal problems. Various authors have described shortcomings in medical student training in fracture care, arthritis and rheumatology, and basic physical examination of the musculoskeletal system. (p. 251).
With continued evidence of lack of musculoskeletal medicine and a subsequent deficiency of training in spine care, particularly of biomechanical (subluxation or bio-neuro-mechanical lesions) orientation, the question becomes, “Which profession has the educational basis, training and clinical competence to manage these cases?” Let’s take a closer look at chiropractic education as a comparison.
Fundamental to the training of doctors of chiropractic, according to the American Chiropractic Association, is 4,200 hours (similar to medical doctors and osteopaths) and students receive a thorough knowledge of anatomy and physiology. As a result, all accredited doctors of chiropractic degree programs focus a significant amount of time in their curricula on these basic science courses. This material is so important to a chiropractic practice that the Council on Chiropractic Education, the federally recognized accrediting agency for chiropractic education, requires a curriculum which enables students to be “proficient in neuromusculoskeletal evaluation, treatment and management.” In addition to multiple courses in anatomy and physiology, the typical curriculum in chiropractic education includes physical diagnosis, spinal analysis, biomechanics, orthopedics and neurology. As a result, students are afforded the opportunity to practice utilizing this basic science information for many hours prior to beginning clinical services in their internships.
It was reported by Shaheed, Mahar, Williams, and McLachlin (2014) that out of the 4,336 studies they identified, there was only 13 found to be relavent, leaving this an area that still needs more review. However, in the entire study it was concluded that, “None of the trials evaluating [medical] advice or bed rest reported statistically and clinically important effects at any time point…The effects of advice on disability are similar to those for pain, with pooled results showing no clinical significant effect for the short and long-terms” (Shaheed, 2014, p. 5). “Pooled results from 2 studies on bed rest showed a statistically significant negative effect of bed rest in the immediate term…” (Shaheed et al., 2014, p. 10).
Shaheed et al. (2014) concluded that “There is no convincing evidence of effectiveness for any intervention available [with] OTC (over the counter drugs) or advice in the management of acute low back pain” (p. 11). The authors did report, “In the intermediate term, results from one of the studies involving referral to an allied HCP [health care provider] and reinforcement of key messages at follow-up visits showed significant effects in the intermediate and long-terms” (Shaheed et al., 2014, p. 12).
A 2005 study by DeVocht, Pickar, & Wilder concluded through objective electrodiagnostic studies (neurological testing) that 87% of chiropractic patients exhibited decreased muscle spasms. This study validates the reasoning behind the later study that people with severe muscle spasms in the low back respond well to chiropractic care and this prevents future problems and disabilities. It also dictates that care should not be delayed or ignored due to a risk of complications. The above statistic indicates that while medicine cannot conclude an accurate diagnosis in 85% of their back pain patients, chiropractic has already helped 87% of the same population.
In a study by Leeman, Peterson, Schmid, Anklin, and Humphrys (2014), there is further successful evidence of the effects of mechanical back pain, both acute and chronic pain with chiropractic care. This study considered both herniated discs and radiculopathy or pain radiating down into the leg as a baseline for analysis. The study also considered acute and chronic lumbar herniated disc pain patients. In this study, the acute onset patient (the patient’s pain just started) reported 80% improvement at 2 weeks, 85% improvement at 1 month, and a 95% improvement at 3 months. The study went on to conclude that the patient stabilized at both the six month and one year marks following the onset of the original pain. Although one might argue that the patient would have gotten better with no treatment, it was reported that after two weeks of no treatment, only 36% of the patients felt better and at 12 weeks, up to 73% felt better. This study clearly indicates that chiropractic is a far superior solution to doing nothing and at the same time helps the patient return to his/her normal life without pain, drugs or surgery.
Again, this is an environment where research has concluded that medicine has poor choices based upon outcomes for what they label “nonspecific low back pain.” The results indicate that chiropractic has defined this “nonspecific lesion” as a “bio-neuro-mechanical lesion” also known as the chiropractic vertebral subluxation and the evidence outlined on these pages, combined with the ever growing body of outcome studies verify that medicine can reverse this epidemic by considering chiropractors as “primary spine care providers” or the first option for referral for everything spine short of fracture, tumor or infection.
References:
Scoliosis and Chiropractic Care
The average reduction of thoraco-lumbar scoliosis was 17.2° and was maintained for 24 months.
Function improved 70% and pain was reduced by 60%.
A report on the scientific literature
BY Mark Studin DC, FASBE(C), DAAPM, DAAMLP
According to the Mayo Clinic (2009), " Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. While scoliosis can be caused by conditions such as cerebral palsy and muscular dystrophy, the cause of most scoliosis is unknown. Most cases of scoliosis are mild, but severe scoliosis can be disabling. An especially severe spinal curve can reduce the amount of space within the chest, making it difficult for the lungs to function properly. Children who have mild scoliosis are monitored closely, usually with X-rays, to see if the curve is getting worse. In many cases, no treatment is necessary. Some children will need to wear a brace to stop the curve from worsening. Others may need surgery to straighten severe cases of scoliosis" (http://www.mayoclinic.com/health/scoliosis/DS00194). They go on to say that signs and symptoms of scoliosis may include, uneven shoulders, "Signs and symptoms of scoliosis may include: uneven shoulders, one shoulder blade that appears more prominent than the other, uneven waist, [and] one hip higher than the other" (Mayo Clinic Staff, 2009, http://www.mayoclinic.com/health/scoliosis/ DS00194/ DSECTION=symptoms).
"If a scoliosis curve gets worse, the spine will also rotate or twist, in addition to curving side to side. This causes the ribs on one side of the body to stick out farther than on the other side. Severe scoliosis can cause back pain and difficulty breathing. Go to your doctor if you notice signs or symptoms of scoliosis in your child. Mild curves can develop without the parent or child knowing it because they appear gradually and usually don't cause pain" (Mayo Clinic Staff, 2009, http://www.mayoclinic.com/health/ scoliosis/DS00194/ DSECTION=symptoms).
According to Lou et al. in 2010, three-dimensional lateral curvatures of the spine affect 2-3% of the adolescent population. According to ACT Youth who utilizes the 2000 US Census Bureau statistics, the number of adolescents in the United States is 41,747, 962. Averaging 2.5% of all adolescents having scoliosis equates to 1,043, 699 children facing issues as result of scoliosis. Lou et al. (2010) continue, "Brace (orthotic) treatment is recommended for growing children with curves of 25–45° Cobb angle. Surgery is the final treatment option for curves greater than 45° and its goals are to obtain safe correction, to produce a solid spinal fusion of the curve region, and to bring the spine and body into a more balanced position (p. 292). However, they conclude, " Although brace treatment for scoliosis has been used for more than fifty years, its effectiveness is still debatable... Most studies used the amount of curve progression (as measured by the Cobb angle) to determine the effectiveness of brace treatment. Some defined success as 5° or less curve progression" (Lou et al., 2010, p. 292).
While allopathic medicine is still entrenched in the debatable practice of bracing and eventually surgery with the eventual progression of scoliosis, there are proven solutions. Morningstar concluded in 2011 that as a result of chiropractic spinal adjusting and chiropractic spinal manipulation, a thoracolumbar curvature (scoliosis) averaged a 17.2° reduction that was maintained for 24 months, the length of the study. Across all spinal groups, an average of 10° reduction was realized that persisted for 24 months, again the length of the study. Morningstar also concluded that pain scales reduced by 60% at 24 months and function improved by 70% while respiratory capacity increased 7%. Although this was a limited study with 28 patients, it is the first scientific conclusion that documents and reflects the results of what chiropractors have been realizing in their offices for over a 100 years.
The real issue is that if adolescents have their curvatures reduced by 10°-17.2°, then bracing and surgery are not an option because they will not be indicated. As bracing has been deemed "highly questionable" in the literature and now the literature reflects chiropractic as a highly effective modality, the standard of care across professions should be chiropractic care for scoliosis as first line treatment and should be standardized in every discipline.
Disc Surgery (Discectomy,) Sciatica (Leg Pain) & Lumbar Disc Herniation
Surgery vs. Chiropractic Care
A report on the scientific literature
by
Mark Studin DC, FASBE(C), DAAPM, DAAMLP
60% of Surgical Candidates Avoid Surgery with Chiropractic
According to a group at MayoClinic.com (2010), "Sciatica refers to pain that radiates along the path of the sciatic nerve and its branches — from your back down your buttock and leg. The sciatic nerve is the longest nerve in your body. It runs from your spinal cord to your buttock and hip area and down the back of each leg. Sciatica is a symptom, not a disorder. The radiating pain of sciatica signals another problem involving the nerve, such as a herniated disk" (http://www.mayoclinic.com/health/ sciatica/DS00516).
Sciatica symptoms include: Pain "…likely to occur along a path from your low back to your buttock and the back of your thigh and calf. Numbness or muscle weakness along the nerve pathway in your leg or foot. In some cases, you may have pain in one part of your leg and numbness in another. Tingling or a pins-and-needles feeling, often in your toes or part of your foot. A loss of bladder or bowel control. This is a sign of cauda equina syndrome, a serious condition that requires emergency care" (Mayo Clinic Staff, 2010, http://www.mayoclinic.com/health/sciatica/DS00516/DSECTION=symptoms).
A prime symptom of sciatica is leg pain in conjunction with herniated discs. As reported by the US Chiropractic Directory in 2010, "Pain radiating down your leg secondary to a herniated disc is a common and often disabling occurrence. A disc in your spine is comprised of 2 basic components, the inner nucleus pulposis that is gelatinous in composition and the outer annulus fibrosis that is fibro-cartilaginous and very strong. When a person experiences trauma and the forces are directed at the spine and disc. The pressure on the inside of the disc is increased (like stepping on a balloon) and the internal nucleus pulposis creates pressure from the inside out. It tears the outer annulus fibrosis causing the internal material to go beyond the outer boundaries of the disc. This has often been misnamed a ‘slipped disc’ because the disc doesn’t slip or slide, it is torn from the trauma allowing the internal material to escape.
Conversely, a bulging disc, which gets confused with a herniated disc, is a degenerative "wear and tear scenario" that occurs over time with the annulus fibrosis degenerating. This can also be a "risk factor" allowing the disc to herniate with less trauma due to the degeneration or thinning of the disc walls. This, however, is a conversation for another article.
Lifetime prevalence of a herniated disc has been estimated to be 35% in men and 45% in woman and it has been estimated that 90% of all leg pain secondary to herniated discs occurs at either the L4-5 or L5-S1 levels. It has also been reported that average duration of symptoms is 55.9 weeks, underscoring the critical necessity for finding a viable solution for these patients" (http://www.uschirodirectory.com/index.php/patient-information/item/235-herniated-discs-radiating-pain-and-chiropractic).
It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbert in 2010 that over 250,000 patients a year undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to non-operative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study.
This study was limited to patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, the patients participating in the study were all initially considered surgical candidates.
Both the surgical and chiropractic groups reported no new neurological problems surfaced and had only minor post-treatment soreness. 60% of the patients who underwent chiropractic care reported a successful outcome while 40% required surgery and of those 40%, all reported successful outcomes. Of those patients choosing surgery as the primary means of treatment, 15% reported a failed surgical outcome and then chose chiropractic as a secondary choice. Of those 15% with failed surgeries, all were reported to have performed worse in clinical outcomes.
While it is clear that an accurate diagnosis could dictate that many patients require immediate surgery, many also do not. The above study indicates that a conservative non-operative approach of chiropractic care prevented 60% from needless surgery. While a larger study would give us more information, based upon the outcomes, cost factors and potential increased risks of surgery, it was concluded that chiropractic is a viable, first line treatment option.
These studies along with many others conclude that a drug-free approach of chiropractic care is one of the best solutions for patients with surgical lumbar discs and sciatic pain. To find a qualified doctor of chiropractic near you go to the US Chiropractic Directory at www.USChiroDirectory.com and search your state.
References:
1. Mayo Clinic Staff. (2010, April 22). Sciatica, Definition. MayoClinic.com, Retrieved from, http://www.mayoclinic.com/health/sciatica/DS00516
2. Mayo Clinic Staff. (2010, April 22). Sciatica, Symptoms. MayoClinic.com, Retrieved from http://www.mayoclinic.com/health/sciatica/DS00516/DSECTION=symptoms
3. Studin, M. (2010). Herniated discs, radiating pain and chiropractic. US Chiropractic Directory. Retrieved from http://www.uschirodirectory.com/index.php/patient-information/item/235-herniated-discs-radiating-pain-and-chiropractic
4. McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33 (8), 576-584
Cervical and Lumbar Disc Herniations and Chiropractic Care
A report on the scientific literature
80% of the chiropractic patients studied had good clinical outcomes
By
William J. Owens DC, DAAMLP
Mark Studin DC, FASBE (C), DAAPM, DAAMLP
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