Once Again Another Study Shows Manipulation Helps Back Pain

Posted in Chiropractic, Manual Therapy Works at 3:58 PM by Dr. Greathouse

Hey it works! Study after study demonstrates this and it’s safe too.

So, if you have back or neck pain, give it a go.


01 April 2013 – Volume 38 – Issue 7 – p 540–548

doi: 10.1097/BRS.0b013e318275d09c

Randomized Trial


Study Design. A randomized, double-blinded, placebo-controlled, parallel trial with 3 arms.

Objective. To investigate in acute nonspecific low back pain (LBP) the effectiveness of spinal high-velocity low-amplitude (HVLA) manipulation compared with the nonsteroidal anti-inflammatory drug diclofenac (anti-inflammatory) and with placebo.

Summary of Background Data. Few studies have evaluated the effectiveness of spinal manipulation in comparison to nonsteroidal anti-inflammatory drugs or placebo regarding satisfaction and function of the patient, off-work time, and rescue medication.

Methods. The subjects were randomized to 3 groups:

(1) spinal manipulation and placebo-diclofenac;

(2) sham manipulation and diclofenac;

(3) sham manipulation and placebo-diclofenac.

Results. Comparing the 2 intervention groups, the manipulation group was significantly better than the diclofenac group (Mann-Whitney test: P = 0.0134). No adverse effects or harm was registered.

Conclusion. In a subgroup of patients with acute nonspecific LBP, spinal manipulation was significantly better than nonsteroidal anti-inflammatory drug diclofenac and clinically superior to placebo.


Homogenizing and Color Coding Back Pain?

Posted in Back Facts (spine), Guidelines for Treatment at 2:44 PM by Dr. Greathouse

If we could homogenize back pain and then color code it, we could get more people better quicker, at less cost!

Can you homogenize back or neck pain, and how the heck do you do it?

Well, the answer to the first part of the question is yes! As a matter of fact it’s been done already. As for how, I’ll explain as we go. As for color-coding, it could be done!

We’ve all heard of homogenized milk, but what does that mean? To homogenize something means to make uniform in consistency. Now, we’re not making back pain uniform or consistent, we are identifying uniform and consisted attributes to back pain that are more likely to respond to certain types of care.  You see, a very high percentage of all back pain is heterogeneous, meaning, made up of all sorts of causal factors, of which we aren’t really able to reliably diagnose as the cause of the pain.

This heterogeneous group, better known as nonspecific back/neck pain, makes up 85% or more of all back and neck problems, and this creates havoc for people with back and neck problems.

It creates havoc because the lion’s share of the studies done on what treatment works best has been done on the heterogeneous/nonspecific group of sufferers for the past 35 years or so. So, in effect, we find that certain treatments are beneficial in some people but we don’t really know why, or how to select which one will most likely benefit from which treatment. Thus, treatment essentially remains trial & error, at the time, expense and suffering of the individual.

We can now identify certain consistent (homogeneous) characteristics of certain subgroups within this constellation of nonspecific spinal pain sufferers and get better results. This is called “clinical prediction rules” and these are now given for a variety of problems which we have difficulty diagnosing.

As for color-coding, once a subgroup has been identified, it should be coded by a matching color to the type of treatment options that are more suited for that subgroup. That’s my recommendation.


Back & Neck Care – A few facts you should know!

Posted in Back Facts (spine) at 12:41 PM by Dr. Greathouse

Most diagnosis’s given by health care providers are no more than (poorly supported), educated guesses. Health science, (all disciplines with the exception of acupuncture, perhaps) cannot identify the true cause of back or neck pain 85% of the time. This 85% is more accurately called “Nonspecific Back or Neck Pain”.

Some of what we can accurately diagnose as a cause of spinal pain, when present, includes the following: Cancer, fracture, systemic arthritis (lupus, rheumatoid), nerve root compression (actual compressed nerve), visceral disorders and infections. Also, trauma or injury causing a sprain of the joint(s) or strain of the muscle(s), although the specificity of which joint(s) and how severe, is primarily educated guess work.

The following are commonly given diagnosis’s that have no basis or cannot not truly be correlated as the cause of back or neck pain: Subluxations (vertebra out of place), osteoarthritis, degenerative disc or joint disease, disc herniations, muscle spasms, muscle imbalance, muscle weakness, uneven pelvis, foot problems, tight hamstrings, tight hip flexors, weak abdominals, etc.

Most healthcare providers will give you a diagnosis, even if it’s poorly supported by science. That’s because, that’s what we’re taught to do and that’s what you want to hear.

Trauma, Injury, or Tissue Disruption
Most people equate injury to a specific event or occurrence that produces immediate pain or somewhat immediate pain associated with the event. Most case histories of back or neck pain do not bear this out. It’s believed that through repetition or prolonged load or stress, tissues (ligaments, discs, cartilage, tendons) can break down over time. This can lead to both mechanical and chemical pain syndromes. This is called Cumulative or Repetitive Stress Injury. Overload to the tissues as in an accident or overload in an acute abrupt manner is commonly called a Sprain/Strain Injury.

Spinal Sprain Healing Physiology
The healing process is broken down into three phases or stages:
1) Acute Inflammatory Phase: May last several days.
2) Repair Phase: May last up to12 weeks.
Beyond 8 to12 weeks, remedial therapeutic care has little to no value.
3) Remodeling Phase: May last up to 12 months or longer.
At this phase, regular therapeutic movement exercise, at home, benefits the most.
Supportive care may be beneficial, but only on an as needed basis!

Non-Specific Neck or Back Pain: This is a category of spinal pain not a diagnosis! As stated above, this category accounts for 85% of all back & neck problems. In the absence of the more serious causes of pain as listed above, the three most common subcategories of non-specific back or neck pain are mechanical, chemical, and chronic spine pain.

Understanding Mechanical Spine Pain
One form of mechanical pain is akin to bending your finger back until you feel pain. If your finger became stiff, it would hurt sooner if you bent it back, than it would if the joint were normal. For various reasons the spinal joints do stiffen and do hurt when we move. Some experts call this Joint Jysfunction. Therapeutic movement improves mobility and thus reduces pain associated with movement. Therapeutic movement is achieved by the clinician, “passively” or by the individual, “actively”. The ultimate goal is always to achieve results independent of the clinician whenever possible!

Mechanical pain can come from tissue disruption on the inside of the joint as well, similar to having a pebble in your shoe or a wrinkle in your sock that irritates or causes foot pain or discomfort. The internal components (cartilage, disc, meniscus, synovium, ligament) of joints can tear, migrate, swell, off-center or generally derange in all sorts of ways. This disruption can, but not always, produce mechanical pain until some return to normalcy is established. These types of mechanical pain syndromes can be demonstrated quite reliably and many times, will respond to therapeutic movements designed to reduce the deranged tissues in the joint. This type of joint problem is commonly called Joint Derangement. Mechanical pain can be associated with swelling or increased pressure on the tissue due to inflammation.

Chemical Pain
Chemical pain refers to the biochemical irritants associated with the inflammation process itself, and is usually associated with some sort of trauma/injury.

Chronic Back or Neck Pain: Chronic pain can be quite complex and difficult to manage. It’s not typically chemical and once assessed properly, many times responds favorably to mechanical forms of treatment.

Clinical Prediction Rules For Manipulation: In spite of this poor ability to diagnose, we can safely narrow down who might benefit from manipulation by means of established “Clinical Prediction Rules”: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2565597/

A McKenzie (mechanical diagnosis and treatment) assessment is the most reliable and valid way, not to mention successful and safe way, to more accurately assess and manage non-specific spinal pain!

If the problem is mild and purely chemical, it many times will resolve through natural course. If the problem is simple and mechanical, you may be able to work it out independently with movement exercises. At times you may need a little help from a healthcare provider to attain the necessary mechanical therapy (exercise, mobilization or manipulation) to resolve the problem. If the chemical pain is significant, along with a mechanical fault, you may need to resolve the chemical problem first, with medication or rest, before the mechanical issue can be addressed.

Surgery For Herniated Discs
In the absence of an obvious compressed nerve on MRI, associated with profound, progressive neurological deficits, surgery should not be performed unless all conservative measures have been exhausted. Studies show that outcomes are predominantly the same one-year later, with or without surgery, even with disc herniation and neurological deficit.

Alternative Anti-inflammatories
To treat chemical pain (inflammation) without drugs, and fewer side effects and less kidney & liver problems associated with anti-inflammatory drugs, Google, “alternative anti-inflammatory supplements”! Ice packs work well, too.

When you see a chiropractor, your plan of care should look and follow something like this:
Initial care will be directed at resolving potential acute/subacute pain and inflammation residuals with use of appropriate modalities as clinically indicated as well as protective activity modification (posture, body mechanics & ergonomic). Frequent breaks from prolonged standing, sitting, repetitive or prolonged activities are recommended. Specific restrictions given on a case-by-case basis.

Disc derangement (bulge/herniation) treatment and self-management procedures.

Remedial therapeutic care will be directed at preservation and improvement of joint & soft tissue mechanical properties by means of passive (doctor generated) and active (patient generated) mobilization procedures (progressive directional movement), as clinically indicated.

Further rehabilitative exercise may be necessary for functional stabilization. This is addressed on a case-by-case basis as clinically indicated.

This plan of care will be carried out on a trial probationary period of two weeks or less. An interim report will follow at that time with an outcome status and additional recommendations.

If in the event the patient fails to improve within this trial time frame or if the problem remains recurrent, a second medical opinion is advised. We will assist the patient in this referral process.

Treatment Expectations
If you are not experiencing good results within 3 to 5 visits (2 weeks), care is not likely going to benefit you. It’s time for another opinion or approach. The natural history of healing in spinal injury is 6 to 8 weeks. Ongoing treatment beyond this time frame rarely makes you better. Most cases are resolved within 3 to 6 weeks, or less.