Common Sense Treatment Progression

     I am seeing a disturbing pattern starting to emerge in regard to the treatment that a typical lower back pain patient goes through prior to seeing a surgeon.  The norm now goes something like this:  The patient goes to his primary care doctor with lower back pain.  His doctor prescribes some medications and orders a MRI.  Sometimes a the patient is referred for some PT, which usually consists of some stretching, massage, and maybe some ball or balance exercises.   If there is any sign of a disc bulge on the MRI, then the patient is referred to pain management for a series of epidural injections.  The next step, should the injections fail to give the patient relief, is referral to a neurosurgeon.  
     When I think about the logical sequence of treatment, it should progress from the least invasive, least expensive care to the most invasive, most expensive care without skipping any steps in between.  Lower back surgery is statistically the least effective and the most expensive care for lower back pain and should be the last resort unless certain red-flag signs are present.  It is generally accepted that the rate of success is about 50%, and a recent study indicates that only 1 in 100 back surgeries are medically necessary.  Injections are not very cost effective either, somewhere around $1500 per injection with most cases requiring a series of three for a total of around $4500.  Injections like these should be used in conjunction with some form of physical treatment because they do not actually fix anything.  The steroids used simply turn off the inflammatory process temporarily.  Don't get me wrong, I have nothing against medical doctors who perform these procedures - I refer many cases to pain management and to neurosurgery every year and they do a fantastic job.  The patients that I refer, will however, never look back and say that they should have tried something else prior to surgery.
     At Northshore Chiropractic, we offer non-surgical treatment for patients suffering from lower back pain and other musculoskeletal conditions.  We take a logical approach that is problem focused and does not skip any of the steps that can potentially save a patient from going through a surgery before it is absolutely needed.  We are happy to co-manage our patients with their medical doctor in order to achieve the best results utilizing the least invasive procedures.  One of the procedures we use is spinal decompression therapy.  It is a non-surgical treatment for bulging and herniated discs that has been shown to be up to 86% effective.  This, coupled with its relatively low cost when compared to injections or surgery, make it a logical step that should be added before these other more invasive and expensive procedures are utilized.

Functional Rehab for Low Back Pain

     There is a problem in traditional rehabilitation for lower back pain.  I see patients every day who, despite the fact that they have had extensive treatment and rehabilitation, still exhibit instability in functional positions.  They almost always describe to me exercises that they were taught that include ball exercises, abdomen strengthening, and the like.  Lumbar core stabilization is, unfortunately, not equal to abdomen strength.  It is all about coordination and co-contraction of the abdominal  muscles and the main lumbar stabilizing muscles that include the multifidus, quadratus lumborum, and pelvic floor muscles.

     Strength does not equal stability.  I have seen some really big and strong athletes who are completely unstable in positions needed for normal daily activities.  Think about some activities that require stability and balance, like riding a bike.  Do you have to be strong to do that?  No! Four year old children can learn to ride a bike pretty easily.  They just  have to develop the coordination needed to perform that action first.

     One thing that I have noticed is that patients have been given a lot of abdominal strength exercises and lumbar strength exercises, but nothing that facilitates the co-contraction patterns that are needed to truly be stable in functional positions such as sitting and standing.  This is the missing element in a great deal of lumbar rehab protocols.  I see no point in performing strength exercises for lower back pain until unstable muscle patterns are corrected.  Otherwise you would just be reinforcing these unstable patterns, making it more difficult later on to address.  

     In my practice, I see many patients who have had disc problems for extended periods of time who have had multiple episodes.  I utilize chiropractic care, spinal decompression , and functional rehabilitation designed to address the instability patterns that develop in response to pain.  Strengthening comes after instability is addressed.  The great thing about this approach is that stability exercises are less strenuous and can be started earlier in care when they can not tolerate strength exercises.  This approach is "phase of care friendly" for that reason and the progression from stability to strength becomes a logical process that progresses as the patient's pain level decreases.  This helps to prevent future episodes from happening over and over due to bad muscle patterns that, if left untreated, continue to cause pain and interfere with normal function.  

Structure and Function

What is chiropractic and what to doctors of chiropractic do?  That is a really good question.  Chiropractors believe that the structure of your body greatly effects how it functions.  Not just how you move around or how fast you can run and those types of things but how you function overall.  We are talking joints, muscles, nerves, ligaments, organs, and everything else.  Your brain controls every cell and organ in your body.  Its nerve signals are sent downward from the brain to the spinal cord and then out to the nerve roots which eventually branch out to innervate everything.  The spinal cord is housed within the bones of your neck and back called the spine and the nerve roots exit from the spine through little holes called IVF's.  When the structure of your spine is altered, bad things start to happen.  First of all, because the structure is altered, joints start to have dysfunction.  They don't move correctly and become restricted.  This in itself is enough to cause cellular breakage, inflammation, and pain.  A recent study showed that joint restriction and immobilization caused joint surfaces to start degenerating within just 72 hours!  Altering structure causes stresses to be taken up unevenly.  Bones form according to the stresses placed on them and uneven stress leads to uneven bone growth.  Whenever I see a bone spur on a X-ray I know right away that there is a structural problem.  I always think of the car alignment analogy here - If the alignment on your car went out one day you might not really even notice anything at first.  Drive another couple of thousand miles with a bad alignment and I can guarantee that you will start noticing that things are not right.  What might start as just an irritating wobble at first could end up becoming a big problem later when you start to mess up tie rods, ball joint, and other expensive parts.  Your spine structure is like this.  Bad alignment left untreated will eventually lead to much worse problems later on such as arthritis, disc problems, nerve problems, joint problems...the list goes on and on.  Structure effects function.  It is as simple as that.  Chiropractors are the very best healthcare professionals that address the structure of your body without invasive procedures or drugs.