Chiropractic case studies

Zoë Corbyn of the Times writes:

http://www.timeshighereducation.co.uk/story.asp?storycode=405427

Can you belive it?

The impeccable Dr Simon Singh (see Kerching for Singh) has slightly bogus looking funding for his SAS and an association with an organisation rife with poor science by the sounds of things. How depressing.

We'll work up some more posts on the problems casued by leg-length inequality (LLI) but I wanted to create a shopping list of the causes of leg-length inequality and came up with the following:

Anatomical:
1. Fracture or disease loss of bone. The classic one.
2. Genetic conditions.
3. Nutritional deficiency leading to leg-length loss.

Functional:
1. Sacroiliac joint dysfunctions leading to pelvic obliquity – and I think the most common, at least in my clinic.
2. The iliosacral joint is restricted on the superior or inferior transverse, or the sagittal axes. This may result from many causes including joint, muscle, osseous or compensatory considerations.
3. Hip joint dysfunction causing compensatory alterations by the joint and muscles that move the joint.
4. I am told that a growth in muscle mass itself. The vastus lateralis muscle appears to push the iliotibial band laterally leading to femoral angle compensations to maintain a line of progression during the gait cycle. This is often misdiagnosed as I-T band syndrome and subsequently treated incorrectly.
5. And the internal rotators of the lower limb being chronically short or in a state of contracture though I hate this sort of diagnosis as there’s never a decent answer to the why?
6. Likewise, short hamstring muscles as these are short because of the leg-length inequality.
7. And apparently, failure or incorrect loading of the Back Force Transmission System (the longitudinal-muscle-tendon-fascia sling and the oblique dorsal muscle-fascia-tendon sling). See the proceedings of the first and second Interdisciplinary World Congress on Low Back Pain.
8. And one I found last week with a patient who has uber lax ligaments and has developed one hyperflexed knee leading to a subsequent low hip on that side.
9. etc.
But the bottom line is look for common things first, identify if they are leg issues or pelvic issues and the and only then start to panic if you can find nothing. However, after a cup of tea and once the ‘why’ is identified you can then start to get things moving.

Any others?

Posted by Rupert Clements of C1 Chiropractic Health Centre.

Sciatica needs chiropractic care, and possibly some other options, to reduce pain in your back and legs.

 

Right, that’s it, I don’t want to hear the cry of: “I have sciatica” ever again unless it has been diagnosed by someone who as a clue.  I’m fed up with having to disabuse patients of this rotten diagnosis; it’s not far off “I have lumbago”.  As a chiropractor here in Bristol, we often have patients coming in for treatment with low-back pain (LBP) and pain running down the back of their legs.  Quite often this has nothing to do with the sciatic nerve and is still called sciatica. 

 

The anatomy:  The sciatic nerve is the longest and widest single nerve in your body.  It branches off at the base of the spine and runs down each side of your pelvic area, supplying nerve impulses to your gluteal region (butt), legs and feet.

 

The pain:  If you've ever experienced sciatica, you know how debilitating this pain can be.  I've seen patients, who could barely walk, couldn't bend over or even stand.  With good care you will be back to your normal self within 2-3 weeks.

 

The solution:  Chiropractic

 

oh, and try:  massage therapy.  I have patients who I see in my clinic that need gentle massage for their sciatic pain.  We use various forms of massage to relax patient's muscles, improve blood flow, and most important, the release of endorphins in the body that act as natural pain relievers.

 

Last but not least, a highly effective technique for treatment that is being used more and more is acupuncture.  A qualified and trained acupuncturist such as our great Zak can provide relief from back pain by simply using thin needles inserted in the area where you feel discomfort

 

There is no guarantee that this or any other combination of treatments will totally eliminate sciatica from reoccurring but if you follow the advice of your chiropractor and seek help early, you should prevent this from happening again in the future.

 

For more information on treatments and alternatives to protect your back, go to www.c1healthcentre.co.uk or contact me personally.

 

Rupert

          I was explaining to a Hungarian ex-gymnast patient about her slight leg-length inequality and the problems this was causing her low-back and she got me with the testing ‘Why?’ question – and, as you all know, this is the best question, and so I took a deep breath and started:

 

Firstly, leg length inequality (LLI) is really common.  A bloke called Knutson found:

 

“Using data on leg-length inequality obtained by accurate and reliable x-ray methods, the prevalence of anatomic inequality was found to be 90%, the mean magnitude of anatomic inequality was 5.2 mm (SD 4.1).”

So that’s all of us; but, as he adds:

 

“The evidence suggests that, for most people, anatomic leg-length inequality does not appear to be clinically significant until the magnitude reaches ~ 20 mm (~3/4").”

 

So it has got to be about 2 cm to be clinically important. 

 

However, for most of our patients it is not anatomical differences in leg–length that actually cause the change but pelvic rotation.  Rarely do people’s arms grow to be different lengths so why should their legs.  What really happens is that their pelvises get rotated.  Due to the cunning anatomy of the pelvis the bones do not rotate around the middle of the sacroiliac joints but about a point just below the bottom of the joint.  This means that if the bone rotates it does so like a cam with it getting higher as it rotates forward and lower as it rotates backwards – trust me on this one, it just does. 

 

Now a good way to test this if you have such a thing happening to you is to look in a mirror and see if your iliac crests are level, if they aren’t and your belt/pants are lopsided and one trouser hem and one shoe is wearing more that the other and then you may well have a leg-length inequality.  However, this doesn’t tell you what’s causing it.  To do this we need to look at the height of your hips without the legs in the equation, so sit down.  Now you are sitting on your ischeal tuberosities – the bits you sit on when you are on a bike and your legs are taken out of the equation.  If your iliac crest is still high when you are sitting then it must be a pelvis issue and we need to sort something out.

 

But how does it happen – well I recon for most of my patients it’s all to do with falling off the swings/tree/bike/footy/gymnastics and all that stuff as a child and it going unnoticed as the change was too small to see.  However, school screenings have shown that LLI is pretty common and I recon should be tackled at this point to prevent them from becoming a problem later because:

 

“The overwhelming majority of patients examined for low back pain of uncertain origin had LLI with asymmetric load distribution.  Furthermore, the overload at the lumbosacral level may produce muscular stress, premature degenerative diseases of the disc-somatic and the interapophyseal joints L4-L5 and/or L5-S1, as well as dysfunction (sometimes subluxation) of the sacroiliac joint, which might give rise to low pelvic pain.  The pain, with or without sciatica, if non caused by herniary pathology, almost always affects the side of the greater load.

Leg Length Inequality, Scoliosis And Low Back Pain.  A. Manganiello.

 

And then I took a breath in.

Research shows that chiropractic can help with chronic neck pain.  Check this artical out:

http://www.ebp-clients.co.uk/c1/wordpress/index.php/chiropractic-can-it-help-chronic-neck-pain/

This massive study (Addition of chiropractic care increases value-for-dollar in US employer-sponsored health benefit plans by Niteesh Choudhry, MD, PhD, and Arnold Milstein, MD) was done in the US and came out today (ish) .  It is a study that merges effectiveness of treatment with the cost of that treatment and compares the result with that of normal medical care.  The quotations I liked were: 

The results of the researchers’ analysis are as follows:

• Effectiveness: Chiropractic care is more effective than other modalities for treating low back and neck pain.
• Total cost of care per year:

-For low back pain, chiropractic physician care increases total annual per patient spending by $75 compared to medical physician care.

-For neck pain, chiropractic physician care reduces total annual per patient spending by $302 compared to medical physician care.

Cost-effectiveness: When considering effectiveness and cost together, chiropractic physician care for low back and neck pain is highly cost-effective, represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds.

And I'd hate to say told you so, but....

Gerard Clum, DC, spokesperson for the Foundation for Chiropractic Progress and president of Life Chiropractic College West, says, “While some studies reflect cost efficiencies and others clinical efficiencies, these findings strongly support both for chiropractic care of neck pain and low back pain.”

 

Low-back pain is costly, debilitating and poorly diagnosed. It affects early everyone, about 80% of the population, at some point during their lives. And thousands of pounds (and billions of dollars and a shed load of Euros etc) have been spent trying to improve clinical outcomes but, incredibly, pain, disability and lost time from work have not improved dramatically over the past several decades.

In about half of all LBP cases have associated leg pain. These cases are the testing ones and they account for a disproportionately large amount of LBP related health care cash. Add to this the fact that LBP with leg pain is an important predictor for chronicity and severity of LBP, so if you have leg pain the problem tends to last longer and be nastier.

But why is the leg hurting?

Several structures are capable of producing referred leg pain. These can range from the neural to the musculoskeletal. And, clearly, a failure to identify the etiology of the referred leg pain can mean that the wrong cause is addressed and the wrong treatment is then, promptly, delivered.

There was an interesting article on this published earlier this year by a Schafer A et al. where they set out an interesting way of thinking about low-back pain with leg pain.

They set out the mechanisms that cause low-back related leg pain as follows:

• Inflammation: Internal disc damage or endplate fractures activate the inflammatory cascade which can cause discogenic referred leg pain or nerve root irritation. Inflammation of the nerve root can also increase the nerve’s sensitivity to mechanical compression and change neural mobility.

• Compression: Mechanical nerve root compression secondary to degenerative changes or a space occupying lesion may result in impaired blood flow to the tissues surrounding the nerve and the nerve itself. This, in turn, can cause increased fluid pressure and mechanical nerve fibre deformation. Nerve root compression can result in sensory and motor dysfunction and radiating pain.

• Central Events: This bit is a tad testing but neural plasticity can occur secondary to continued stimulus from nerve fibres associated with handling pain (nociceptive) input. This may result in a lowered threshold to nociceptive input, changes in subcortical and cortical brain regions, disinhibition and a phenotypic switch of non-nociceptive neurons to nociceptive neurons. This is called central sensitization.

• Musculoskeletal Referral: Pain generators can include the intervertebral disc, facet joint, sacroiliac joint, or a variety of myofascial structures. All of these structures have been sufficiently studied and identified as potential leg pain generators and their pain patterns well mapped by the likes of Travell and Simon.

So the authors of the paper propose that low-back pain with leg pain should be grouped into 4 groups that would be treated differently because their causes are different – sensible really. The groups are:

• Central Sensitization - with thermal and mechanical increased response to pain stimulus (hyperalgesia)/extreme tenderness of the skin (allodynia) and neurological evaluation may reveal altered pin prick thresholds or light touch allodynia (oh yes indeed).

• Denervation - structural nerve damage with altered motor strength, deep tendon reflex, and/or sensation in a dermatomal pattern.

• Musculoskeletal - absence of gross neurological deficits and absence of nerve root tension and positive joint provocation manoeuvres or centralization/peripheralization.

• Peripheral nerve sensitization - absence of gross neurological deficits and presence of nerve root tension – referred leg pain with neural movement during testing.

And of course not forgetting that you can have more than one at once – and this is not uncommon:

• Mixed Pathologies - multiple pathologies may be present at once but the authors think the existence of a primary mechanism responsible for a patient’s symptoms can be determined and therefore tackled.

So at C1 we are looking to make this call and we’ll include in our initial examination a comprehensive assessment of the patient’s subjective complaint. We’ll then carry out a physical evaluation, including a neurological examination, an assessment for nerve root tension, an evaluation of active ROM and joint provocative testing.

Look what they are saying in Parliament about the GCC and the faintly obsessed:

There are also serious problems in chiropractic, which one might call an assisted discipline to osteopathy. The General Chiropractic Council has been bombarded by complaints from bloggers—spurious complaints I would say—which it is obliged by law to investigate. I am very concerned that genuine complaints will not get through and that any practitioner, against whom a genuine complaint had been lodged, could continue to practise. Will the Minister look at this very unsatisfactory situation, which arose following an individual losing a court case against the British Chiropractic Association?

David Tredinnick MP

 

We are always banging on at our patients to drink more water and suggesting the right amounts that they should be drinking.  They rightly ask how much and we tell them.

 

This is the score:

 

You lose:

 

Normal Weather        Warm Weather          Warm Weather

No exercise                No exercise                Exercise

 

Skin (not sweat)       350 ml                          350 ml                          350 ml

Sweat                        100 ml                          1400 ml                        5000 ml

Respiratory Tract    250 ml                          350 ml                          650 ml

Urine                         1400 ml                        1200 ml                        500 ml

Faeces                       100 ml                          100 ml                          100 ml

 

Total                          2,300 ml (2.3l)             3,300 ml (3.3l)/            6,600 ml (6.6l)

 

So, a fair bit every day. 

 

Now you do get water from your food and from metabolic water production (Google it), typically about 1.5L, so we suggest:

 

Sedentary individuals drink at least 2L or about 8 cups of water per day

 

Athletes in normal climates drink at least 3L or about 12 cups of water per day.

 

Athletes in hot weather climates drink at least 4L or about 16 cups of water per day.

 

Well, this is a philosophy piece from me and I want to take a few steps into the wide blue on this one which may challenge some of you and interest others as I start to look at what is really causing all the back pain we encounter.

Firstly, here’s a thought to kick off with: seen any cats with back pain recently? Seen your local herd of cows queuing for anti-inflammatory drugs at your GP? No, didn’t think so but, as I tediously hammer into my kids, the key question is why? Why is this? What are they doing right and what are we doing wrong? (and at this point I accept that some dogs and some horses do see chiropractors but this may well support the point I’m making, so hold on).

The answer lies in what they were designed to do. Cats are designed to be cats and cows, cows and they generally haven’t changed much in what they do – yes, cows have got fatter and bigger and more milky and cats have got more manipulative and cooler but they are essentially what they were designed to be and they are essentailly doing the things they were designed to do.

Now, is this the same with you and me? Well, your design criteria landed on your designers’ desk some 4.5 million years ago, your prototype did its first test-lap 1.5 million years ago you came into full production ½ a million years ago. The original, glossy, design criteria manual had a load of chapters setting out what you should be able to do, such as run fast for a short distance to dodge sabre-tooth tiger, run long distances to chase down mammoth, throw rocks and whittle sticks. But, and this is a big but, it didn't have an annex called “Future Proofing”. This missing annex should have had chapters such as sitting down for 8 hours a day, moving your arms in a 2 foot by 4 foot square in front of you and eating enormous amounts of calories whilst doing nothing and expecting to survive.

And this is the key. You are designed for one thing - active, upright, hunter-gatherering, and doing another – sedentary, desk-flying, computer operator. So this is similar in its wrongness as using the family car as a 4X4 cross-country thing (which yours may be but then you are morally wrong and must change it). Yes, it’ll do the job but it will eventually go wrong.

The brutal detail and the exceptions to this rule are legion however the essence is here. If you have something going wrong with your back the question you must ask yourself is: “would my Palaeolithic ancestor be doing what I am doing” and if the answer is no you have a feel for why you are failing.

Now, all we need to do is sort it out…

And that’s another hill of beans.