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low back pain

Preventing Back Pain in Adults

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If you have been reading this blog, you know by now that back pain is a huge problem in our society. In affects over 80% of people at least once in their lives, and can lead to high costs in terms of diagnostic testing/imaging, treatment, medication, decreased productivity and time off work.

A systematic review was recently done in The Spine Journal to evaluate which methods were best for preventing back pain in adults. They evaluated studies including exercises, advice, back supports and other props, activity modification or social/workplace policy changes.

What they found is that the only intervention that consistently showed good results in preventing the occurrence of back pain was exercise. This reinforces the general tenet that you must get your back in motion for it to be healthier.

A simple, but consistent exercise plan is a vital component to healing existing back problems, and more importantly to stop them from recurring. Exercise, whether general aerobic or specific strengthening/mobilizing should be part of every patient’s plan of manangement.

Dr. Debbie Wright is a practicing Courtenay Chiropractor.

Exercise for Chronic Pain

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For years research has been conducted into the benefits of exercise for chronic low back and neck pain. Even though we know exercise is good for us, we don’t really know a lot about how it is prescribed in real-life situations (practice).  Recently, a large survey was done of 2700 people who reported having chronic neck or low back pain. The results are published in an article in Arthritis & Rheumatism.

Of these 2700 people, 48% had been prescribed exercise after visiting a physical therapist, chiropractor of family doctor in the past year. 33% of all people who visited a chiropractor were prescribed exercise for their pain, compared to 64% of PT patients and 14% of MD patients. Overall, the type of provider, as opposed to any characteristics of the patient was the greatest predictor of exercise prescription.

With chiropractic specifically in this instance, the rate of exercise prescription seemed to increase with number of visits. This supports the common practice pattern of reducing pain and increasing function before commencing rehabilitation.

This is a huge wake up call to all health care providers – exercise was prescribed to less than half the patients with chronic back pain, even though we know it is one of the most effective forms of treatment. We need to make sure we are getting our patients active, and helping them to stay that way!

Dr. Debbie Wright is a practicing Comox Valley Chiropractor.

Exercises For Spine Stabilization

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Over the years, research has clearly shown that exercise and stabilization of the lower back are key to making a full recovery from back pain. Stu McGill, a leader in this field of research has consistently guided our thinking in terms of specific exercises that optimally stabilize the spine, while minimizing the amount of stress and strain on its structures (disc, joint, ligament etc.).

An article published in the Archives of Physical Medicine and Rehabilitation further clarifies our knowledge when it comes to stabilizing exercises for the low back. This study focuses on the three main exercises recommended for back stabilization, and aims to help guide clinicians in determining how to progress patients through these exercises.

Curl UpCurl Up: This classic curl-up involves keeping one leg straight, one leg bent, both hands under the back and curling the shoulder blades up off the ground. Progressions can involve pre-bracing, adding in arm movements (dead-bugs), and deep breathing during the exercise.

Side Bridge

Side Bridge: This involves lying on your side with our elbow and knee on the floor, while lifting the hips up off the ground and holding. Progressions can involve using feet instead of knees as lower balance point and moving arm positions.

Bird DogBird Dog: This involves starting on all fours with hips and shoulders at a 90 degree angle. Progressions can involve raising one arm, one leg, opposite arm and leg together, and movements of the limbs while elevated.

These three simple exercises are easy for clinician’s to prescribe, and can be done safely by a patient with little or no supervision. Its important for us to take the time to teach these exercises properly, so patients can attain the improvements they need with minimal stress on their spine.

Dr. Debbie Wright is a practicing Comox Valley Chiropractor.

Routine X-rays Not Needed

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Following up on my previous post about the necessity of X-rays, I came across a review of the literature for low back imaging.

In 1994, the AHPR began recommending against imaging of the low back in the early stages of acute low back pain. This study was undertaken to investigate the relationship between the use of immediate X-rays for the low back and the clinical outcome of the case.

479 articles were identified and reviewed. The authors found no differences in long term and short term outcomes between those who were X-rayed immediately and those who simply received treatment.

They concluded that for patients who present with simple uncomplicated low back pain (no red flags present), X-raying their back did not lead to any greater improvements. Since there is no benefit to imaging the back, but there are draw backs (radiation exposure, cost), routine imaging should be avoided.

Ultimately, every clinician has to rationalize their decisions when it comes to the assessment and treatment of their patients. I will often explain my decision not to X-ray with the fact that the X-ray result will not change my clinical management of their case. We know already from previous studies that many things are seen on X-ray and MRI that don’t have clinical relevance and may actually confuse the issue.

If you would like to read the original article, it can be found here.

Dr. Debbie Wright is a practicing Comox Valley Chiropractor.

Alexander Technique Can Help

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As a Comox Valley Chiropractor who’s practice is mainly comprised of back pain, neck pain, headaches and other limb pain, I often hear of people’s adventures with other forms of treatment.  Many of these techniques are “named techniques”, or in other words they are named after the person who invented them. One of the techniques I hear about from time to time is the Alexander technique, and I dind’t give it much thought until this article appeared in the British Medical Journal.

In this study, 579 patients were randomly assigned into 4 different groups, and each intervention was applied with and without general exercise prescription:

  1. Normal care from a GP
  2. 6 massage therapy treatments
  3. 6 lessons of Alexander technique
  4. 24 lessons of Alexander technique

Questionnaires were completed at 3 and 12 months. Overall, there was little improvement in the control group, while at 3 months significant improvements were found in the other 3 intervention groups. The massage benefits did not last through 12 months, while both the  Alexander technique lesson groups maintained their benefits. In fact, the group which received 24 lessons acutally showed a better result at 12 months than at 3 months. When exercise was added to the interventions, it significantly improved the outcome of the 6 lesson group, but not the 24 lesson group.

This is a very large and well-structured study showing the potential benefits of the Alexander Technique in improving pain and disability levels for chronic back pain patients. Obviously this is just one study, but the fact that this study involved many clinics and many different practitioners gives it more validity. Below you will find a video produced by the BMJ demonstrating the Alexander Technique and describing their research.

Dr. Debbie Wright is a practicing Comox Valley Chiropractor.

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The Evidence Supports Chiropractic Care

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Myth #3: There is no evidence to support that chiropractic works.

I don’t even know where to start with this one. The fact is that there is are so many studies done on spinal manipulation that a Medline search would be overwhelming. Instead of going through the many systematic reviews and meta-analyses that exist, I think the evidence is well summed up by an review exploring international low back pain guidelines. The review can be accessed here.

Over the last 10 years, 12 countries have done critical reviews of the scientific literature concerning low back pain. The international consensus is that the balance of the evidence shows that chiropractic spinal manipulation is effective in managing low back pain, and therefore is included in the recommendations. Here is a summary of their findings:

Clinical practice guidelines for the treatment of acute lower back pain

  • Reassurance of the favourable natural history
  • Advice to stay active
  • Discourage bed rest
  • Acetaminophen, p.r.n.
  • Chiropractic spinal manipulative therapy
  • Advice against passive physiotherapy modalities, prolonged bed rest or specific back exercises.

Essentially the investigators found that following these treatment guidelines (including chiropractic spinal manipulation) led to better outcomes than usual medical care. It is important to note that the guidelines don’t recommend chiropractic as a stand alone treatment, but as one component of a continuum of care.

One of the authors of the study then went on to launch the 2-part C.H.I.R.O study (Chiropractic Hospital-Based Interventions Research Outcome study). The first part pitted chiropractic care (along with the above guideline recommendations) versus usual medical care. The people who received chiropractic care showed better functional and quality of life improvements. The results of this study have been presented at Canadian Spine Society Meeting, the International Society for the Study of the Lumbar Spine, and the North American Spine Society and will be published in an upcoming edition of Spine. A summary of the results can be found here.

In the opinion of this Comox Valley Chiropractor, we are so far past establishing that there is evidence supporting chiropractic care. We are now heading in the direction of trying to establish how to best use this tool in the management of patients, or whether certain subsets of patients will respond more favourably. In the past 5 years, Chiropractic Research Chairs have been established at many universities across Canada in order to further chiropractic research.

Dr. Debbie Wright is a practicing Comox Valley Chiropractor.

MRI and the Wary Chiropractor

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Here in Vancouver, the wait time for a non-emergency MRI can be upwards of 6 months unless you’re lucky enough to get in on a cancellation. It is not uncommon in my office to have people recovered well before their MRI appointment comes around. It often spurs a conversation about the need to get an MRI, specifically for low back disc and nerve problems. Often, the patient will want to go for the scan anyways, just to see the state of their discs and get a good picture of what’s going on. I frequently disagree with this idea, for the simple fact that an MRI is not always what it seems.

What do I mean by this?

It has been well documented in the research that when it comes to the low back, MRI findings do not predict the occurrence of actual low back pain. One of the first studies on the subject was published in the New England Journal of Medicine in 1994. They took 98 people who had never had low back pain and gave them an MRI. What they found was that 52% of all people had at least one disc bulge, with 27% having a disc protrusion (more severe). 38% had a problem at more than one level, with the likelihood of finding problems increasing with age. This led the authors to conclude that the finding disc bulges or protrusions in people with low back pain is frequently simply a co-incidence.

A better designed study was published in 2001 in the Journal of Bone and Joint Surgery.  In this study, the authors subjected 67 people without any symptoms to an MRI in 1989. They found that 31% of these people had some sort of disc abnormality. They then followed up with these same people 7 years later to determine if the abnormal findings in 1989 had lead to the development of back pain in later life.  While they did find that the second scans showed more abnormalities than the ones done seven years earlier,  the findings on the scans did not predict whether someone got low back pain or how bad the pain was.

In my opinion, there are very good reasons why someone should go for further scans – a history of cancer, progressing neurological problems, or severe worsening of the problem to name a few. It is, however, important to realize that an MRI may just be a red herring in the search for the cause of the problem. It is especially important in this day and age of ballooning health care costs to use our resources in the wisest manner possible, and not as a first line of investigation if its not warranted.

Management of Chronic Low Back Pain

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Chronic low back pain has been the subject of much research and funding, with very little relevant information coming from the effort. It is a very difficult condition to manage, and its effect on society can be valued into the billions of dollars. However, it is also a condition that is seen with much frequency at the office of this Comox Valley Chiropractor.

A recent study in the prestigious journal Spine set out to analyze the evidence-based management of chronic low back pain with electrical stimulation, interferential current, ultrasound and hot/cold packs. These modalities are used often in the offices of manual medicine practitioners, usually with the goal of relieving pain and inflammation.

What was surprising about this study was the blatant lack of evidence to support the use of these modalities, especially given that they are so prevalent.  No eligible studies of good quality were even found for interferential current, ultrasound and hot/cold pack therapy, leading to the suggestion that these modalities should be avoided. Of the 6 studies that were found for electrical stimulation, 4 were of very poor quality and the remaining 2 found benefit only in the short term. These results suggest that electrical stimulation should be used as only one component of a short term treatment plan (and not on its own).

This article was part of a special edition of Spine in which many different treatments were analyzed for their effectiveness. The general consensus is that not enough research exists to choose one specific treatment over another, however “when viewed optimistically, the articles in this special focus issue do suggest that a reasonable approach to CLBP (chronic low back pain) would include education strategies, exercise, simple analgesics, a brief course of manual therapy in the form of spinal manipulation, mobilization, or massage, and possibly acupuncture.”  Haldeman S, Dagenais S. What have we learned about the evidence-informed management of chronic low back pain? Spine J. 2008 Jan-Feb;8(1):266-77.

If you have any questions about chronic low back pain, feel free to contact your Comox Valley Chiropractor.

Chiropractic Care Better Than “Usual Care”

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A recent article in Lippincott’s Bone and Joint Newsletter caught this Comox Valley Chiropractor‘s eye concerning the effectiveness of chiropractic care when compared to “usual care” given by family doctors. The main author of the study is Dr. Paul Bishop, DC, PhD, MD, a professor of orthopedics at the University of British Columbia.

The study was presented at the International Society for the Study of the Lumbar Spine in Hong Kong. The results indicated that following the existing clinical practice guidelines (which include chiropractic spinal manipulation) produces better outcomes than family doctor-directed care for acute low back pain patients.

The guideline based care involved avoiding passive treatment, acetaminophen to control pain, reassurance and four weeks of spinal manipulation performed by chiropractic doctors at a frequency of two times per week. All patients returned to work within eight weeks.

Using pain and disability questionnaires, the chiropractic treatment group was found to have a significantly greater improvement than those who received “usual care” from their family physicians.

It was also stated that,

“Typically, the family physician-based care involved excessive use of passive therapies such as massage and passive physical therapy, excessive bed rest, and excessive use of narcotic analgesics, Bishop added.”

The evidence continues to mount that chiropractic care is an effective form of treatment for low back pain, and should be used as a first line of treatment for uncomplicated cases.