This article on Yahoo News caught my eye today.  Americans are spending $86 billion a year for lower back pain treatment, but research finds little evidence that the population got better as spending soared over the last decade.

There is an attitude that, with all the fancy, high tech gizmos like digital x-rays and robotic assisted surgical machines that something invasive can and must be done to treat lower back pain.  The reality is that time is often the best antidote.   However, this advice does not sit will with most people with back pain.  People are accustomed to seeking out immediate cures to their maladies and have a certain fear if something is not “being done.”

The biggest problem: When it comes to back pain, there’s no one-size-fits-most treatment.  What may work for one case of back pain may make another case worse, depending on the source of the pain.

“There are a lot of procedures going on for patients in whom we don’t have good evidence that it’s going to help,” said Dr. Richard Deyo of Oregon Health and Science University in Portland, who long has studied how people fare with different options for this tough ailment.

The article goes on to say that exercise rehabilitation, where patients push past the pain, shows encouraging results.  Surgery tends to have a low success rate, because with each successive surgery scar tissue and weakened structures are created potentially resulting in further weakness, loss of stability and mobility, and more pain.

One thing the article failed to mention was chiropractic treatment.  Chiropractic has certain advantages over surgery and pain injections in that it is less invasive and destructive.  When combined with exercise rehabilitation, chiropractic is a very good choice for most cases of lower back pain.  However, it is a procedure and should be recommended only when the condition warrants it.  Cases of severe disc herniation, for example, would not benefit from chiropractic in the acute stage, but may benefit in the post acute stage.

Here is the closing summary of the article:

What’s the best advice? First, some types of back pain are accompanied by red flags that need immediate attention — such as numb or weak legs or urinary problems. But for most people:

_Don’t expect an X-ray, MRI or CT until a month to six weeks has passed, unless the doctor suspects a more serious problem. Following that guideline is becoming a quality-of-care measure in many organizations.

_Get back to normal activity as quickly as possible; the days of prescribed bed rest are over.

_Patients with sciatica, pain radiating down the leg, have the best outcomes from those nerve-easing decompression surgeries, Deyo stressed. California’s Rosen said three criteria determine chances of success: a scan that correlates with the pain site; the patient has some weakness; and specific pain occurs when the doctor raises and straightens the legs.

Herniated disks heal on their own over about two years, but surgery for a faster fix is reasonable in good candidates, he said.

_Fusions are appropriate for far fewer patients, those with fractures, unstable or slipping spines, curvature of the spine and rare other reasons, Rosen said.

_Deyo recently studied surgeries for stenosis, that painful narrowing, and found decompression surgery as effective and less risky than fusions, which are more complicated and costly.

_A formal exercise program is especially effective if coupled with cognitive behavioral therapy that teaches patients to manage and function with pain, Deyo said.

_What if surgery fails? Usually, it was the wrong operation or the wrong candidate, said Rosen, who sees one or two patients a week classified as having “failed back syndrome” because of multiple failed surgeries.

Always get a second opinion. Rosen, who founded the Association for Medical Ethics, also recommends asking about a doctor’s ties to companies that make spine-surgery products. That way you’ll feel assured that a recommendation to cut doesn’t come from a too-cozy relationship.

_Not a good candidate? A primary care physician can be a neutral adviser in helping navigate next steps. Patients with more challenging back problems may fare better at a multidisciplinary spine center with numerous specialists — in rehab and pain management — under one roof.

Dan Perez, DC

(415) 627-9077

Image by Kare_Products via Flickr

I ran across this very informative article today.  Everyone pretty much agrees and understands that prolonged sitting is bad for your back.  I’ve been educating patients about this from day one of my career as a chiropractor.  The body is designed to be upright most of the time, and frequently moving.  Sitting disengages the activity of critical muscles used in posture and can lead to muscle weakness and less support to the spine, leading to degenerative joint disease and chronic back pain.

This article confirms this and goes further to state that prolonged sitting can actually increase your bad cholesterol levels! Here’s what it says:

If you’re standing around and puttering, you recruit specialized muscles designed for postural support that never tire,” (Missouri microbiologist Marc Hamilton) says. “They’re unique in that the nervous system recruits them for low-intensity activity and they’re very rich in enzymes.” One enzyme, lipoprotein lipase, grabs fat and cholesterol from the blood, burning the fat into energy while shifting the cholesterol from LDL (the bad kind) to HDL (the healthy kind). When you sit, the muscles are relaxed, and enzyme activity drops by 90% to 95%, leaving fat to camp out in the bloodstream. Within a couple hours of sitting, healthy cholesterol plummets by 20%.

The data back him up. Older people who move around have half the mortality rate of their peers. Frequent TV and Web surfers (sitters) have higher rates of hypertension, obesity, high blood triglycerides, low HDL cholesterol, and high blood sugar, regardless of weight. Lean people, on average, stand for two hours longer than their counterparts.

The chair you’re sitting in now is likely contributing to the problem. “Short of sitting on a spike, you can’t do much worse than a standard office chair,” says Galen Cranz, a professor at the University of California at Berkeley. She explains that the spine wasn’t meant to stay for long periods in a seated position. Generally speaking, the slight S-shape of the spine serves us well. “If you think about a heavy weight on a C or S, which is going to collapse more easily? The C,” she says. But when you sit, the lower lumbar curve collapses, turning the spine’s natural S-shape into a C, hampering the abdominal and back musculature that support the body. The body is left to slouch, and the lateral and oblique muscles grow weak and unable to support it.

So there you have it.  If you have a job that involves sitting for more than 20 minutes straight (very common in the Financial District of San Francisco), you’ve got to take action and break the cycle– stand up and stretch every 20 minutes; try using one of those “knee chairs” that distributes some of your weight to your knees and legs and preserves the S-curve of the spine; or even consider asking your boss if you can ditch the chair and have a standing work station.  Bottom line– prolonged sitting is bad for your back, and bad for your health!

If you haven’t been in awhile to get your spine adjusted, now’s a good time.  Adjustments help your vertebrae move better, which is critical for those who sit for long periods.

Dan Perez, DC

San Francisco Chiropractors

Most people who are experiencing unrelenting back pain can’t stand the thought of getting surgery.  They will exhaust all non-surgical options first, and if the problem persists, will wait it out hoping that the condition will eventually resolve.

While chiropractic, physical therapy, and a preventive program of back exercises can spare the need for surgery there are some conditions where surgery is the only viable option left.  These include:

• disc prolapse– where the inner nuclear material of a disc has ejected into the spinal canal and is pressing against the spinal cord and/or a nerve root causing symptoms (tingling, weakness) down the legs;
• severe degenerative disc disease, where one or more discs has lost most of its fluid content, has developed painful fissures, and is allowing the surfaces of adjacent vertebra (vertebral bodies) to come into contact with each other;
• spinal stenosis– a condition where the spinal canal narrows from bone spurring/ degeneration and obstructs the spinal cord.

In each of the above cases, a physical element deep within the spine is precipitating the pain to the point where manual therapies and exercises alone cannot reverse.  These patients are referred to an orthopedic surgeon specializing in spinal surgery.  The surgeon will usually order an MRI to assess the severity.  Then, a consultation will be scheduled where the patient will be informed of his options, and what to expect.

So the question becomes, is there anything one can do to avoid developing back problems that require surgery?  The answer is yes.  Here’s how:

1.  Lose the weight (if this applies to you).  Carrying those extra pounds over the years will place additional stress on your lower back, potentially weakening your discs over time.

2.  Stop smoking.  Smoking is known to interfere with proper tissue regeneration.  If you strain your back and you’re a pack a day smoker, it may not heal properly. increasing your risk for future injury.

3.  When at work, avoid prolonged sitting.  Get up and stretch a couple of times each hour to decompress your back and exercise your spinal joints.

4.  Lift properly:  kneel down, hold object close to your body, use your leg muscles, and try not to twist your back while carrying something heavy.

5.  Strengthen your core.  Your core consists of your abdominals (front and side) and lower back muscles.  The significance of these muscles is that they support your lower spine from the front and the back, much like a tent pole is supported by opposing wires.  If one set is weak, you will be more prone to developing back problems.

6.  Watch the activities that require repetitious jumping:  weekend basketball, badminton, volleyball, dancing, improper running.  Only do in moderation.

7.  Get a good mattress.    Don’t skimp on your mattress; you are spending a good amount of your life on a mattress.  Get one that provides excellent support.  TempurPedic is the one I recommend (I also sell them at my clinic as a Professional distributor).

And, consider getting regular chiropractic check ups.  Over time, the pelvis can get unbalanced and vertebrae can get locked together.  Spinal adjustments can restore movement, which will help keep your spine healthy.

Low back pain can be caused by trauma (injuries), arthritic disease, disc problems, and bone disease.

But what if none of these applies to you, and you have recurring lower back pain?

One of the things I noticed over the years is that “uneven leg lengths” can promote recurring low back pain.  The term needs clarification, because everyone’s leg length should be the same (unless you had a leg injury).  The more accurate term is having an “apparent short leg” while lying down straight.

Do this (get your housemate to help first):  Take off your shoes and lie down on your carpet, straight.  An imaginary straight line should pass between your eyes, through your navel, and split your legs evenly.  Have your housemate touch your heels together: are they lined up evenly at the bottom, or are they uneven?  If they are uneven, the “higher” heel refers to the apparent short leg.  Such a discrepancy usually means that your pelvis is tilted to one side as it rests on top of your legs when you stand.

If your pelvis is crooked, it forces your lower back to bend sideways to remain upright.  This can be a source for lower back pain.

If you’ve ever fell hard on your seat, were in a car accident or had a sports injury in your life (even during childhood), these are the types of events that can cause your pelvis to tilt to one side, which leads to lower back pain.

If you feel this applies to you, make sure to get checked:  a course of spinal adjustments can help reduce the imbalance, and custom-made shoe orthotics with a small heel lift can be very helpful.

Till next time,

Dan Perez, DC
(415) 627-9077