Chiropractic case studies

          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.

Glucosamine - and that other good stuff
We’ve been banging the drum about this stuff for some time now and the evidence is very clear that this is good stuff. But what should you take? What you are after is called glucosamine and chondroitin. This stuff is described as the ‘cement of the connective tissues’ and this includes the cartilage that covers the ends of your bones. This acts as a shock absorber and helps your joints move smoothly.

Not Chondroitin but Glucosamine
Chondroitin is, spookily, produced mainly from shark cartilage extract. Unfortunately there is a huge inconsistency in the concentrations of chondroitin extracted from this source and the source has just got to be wrong. Also, its benefits are somewhat dubious and no conclusive studies are available at present. Helpfully, the body manufactures its own chondroitin from glucosamine and so its addition to your supplement is unnecessary.

So, why should you take a supplement?
The matrix that your cartilage is built from is inert stuff; it has little or no direct blood supply and only few cells to keep it maintained. Add to this the fact the stuff itself is not widely available in your diet and, as a double whammy, it also is not very well absorbed by your guts. Now, if you damage your joints or they are suffering from ‘fair wear and tear’ then your cartilage will be damaged. If this occurs the body tries to repair it but with little of this building material available. So the idea behind supplements is that you make sure that your body has enough of the stuff to allow the cells in the cartilage matrix to effectively repair the cartilage.

Which type of Glucosamine is best?
If you don't have a shellfish allergy then D-Glucosamine Sulphate 2KCl is the stuff. This is manufactured from shellfish. If, however, you do have a shellfish allergy then D-Glucosamine Hydrochloride (HCl), which is synthesised from a protein taken from shellfish, is the stuff for you. Generally speaking, shellfish allergy is caused by other constituents within the shellfish, not the protein!

Then there is the Powder v liquid v solid debate
Glucosamine is available in the following forms:
Pure Powder
Capsules
Tablets / Caplets
Liquid (Joint Formulas)

Pure powder is the best option and then mixed with liquid of your choice (a fine deep red is my suggestion). It is the most bioavailable to your digestive system and the most economical. Liquid formulations are best for absorption however you are often paying for the suspension liquid when it's the Glucosamine that does the job. Tablets mean that you are paying for the ‘binding and bulker’ in the tablet and they have a tendency to pass straight through. Finally, capsules, with out any bulking ingredients or flow agents, are also pretty good.

So it's best to buy pure powder and add it to a liquid of your choice. If, however this is not available, then any is better than none. And where possible they should contain HCL and Sulphate

How much should you take?
The recognised dosage for Glucosamine is 1,500mg per day but evidence has shown that:
If you weigh less than 180 lbs take 1500 mg/day
If you weigh more than 180 lbs take 2000 mg/day

This can be taken either in one dose ie 1,500mg in a go or split in to equal doses ie 500mg three times a day and it is best with food.

What does it taste like?
Glucosamine Hydrochloride (HCl) is naturally sweet tasting with a hint of bitterness - hard to describe but not at all unpleasant. Glucosamine Sulphate 2KCl tastes sweet and very slightly fishy! Something like very, very mild prawn cocktail crisps, again with a touch of bitterness. Glucosamine Sulphate NaCl tastes slightly salty and fishy and knowing how it is made this seems reasonable.

Side Effects
Allergic reactions to this supplement appear to be rare. At the suggested adult dosage of 1,500mg per day, adverse effects have been limited to mild, temporary gastrointestinal upset e.g. mild nausea, vomiting, constipation, diarrhoea and dyspepsia, and, rash, drowsiness, headache and insomnia. In one trial, people with peptic ulcers and those taking diuretic drugs were more likely to experience side effects. (Ref 1)

In 1999 the first case of an allergic reaction to oral Glucosamine Sulphate was reported (Ref 2). And pregnant or lactating mothers should not use it due to lack of data on long-term safety and if you have a reaction or one of the symptoms mentioned above, stop taking the supplement and consult your G.P.

Links with Diabetes
People with diabetes should consult with a doctor and have blood sugar levels monitored if they are taking glucosamine. Animal research has suggested the possibility that glucosamine could contribute to insulin resistance (Ref 3,4). Theoretically, this could result from the ability of glucosamine to interfere with an enzyme needed to regulate blood sugar levels (Ref 7). However, available evidence does not suggest that taking glucosamine supplements will trigger or aggravate insulin resistance or high blood sugar (Ref 8). Two large, 3-year controlled trials found that people taking Glucosamine Sulphate had either slightly lower blood glucose levels or no change in blood sugar levels, compared with people taking placebo. (Ref 9,10)

Until more is known, people taking glucosamine supplements for long periods may wish to have their blood sugar levels checked.

And those with High Blood Pressure
Some Glucosamine Sulphate is processed with sodium chloride (salt), which is restricted in some diets (particularly for people with high blood pressure).

Alternatives to Glucosamine
If you've tried the different forms of Glucosamine and they didn't suit you then try MSM (Methylsulfonylmethane). MSM has a much smaller, biologically active sulphur molecule than any of the glucosamines and rarely causes an allergic reaction!
Natural pine tree source MSM is highly bio-available according to radio-labelled studies. Again, it's important to check the source as most MSM is manufactured from petrochemical source

References
1. Tapadinhas MJ, Rivera IC, Bignamini AA. Oral glucoseamine sulfate in the management of arthrosis: report on a multi-centre open investigation in Portugal. Pharmatherapeutica 1982;3:157-68.

2. Matheu V, Bracia Bara MT, Pelta R, et al. Immediate-hypersensitivity reaction to glucosamine sulfate. Allergy 1999;54:643-50.

3. Virkamaki A, Daniels MC, Hamalainen S, et al. Activation of the hexosamine pathway by glucosamine in vivo induces insulin resistance in multiple insulin sensitive tissues. Endocrinology 1997;138:2501-7.

4. Rossetti L, Hawkins M, Chen W, et al. In vivo glucosamine infusion induces insulin resistance in normoglycemic but not in hyperglycemic conscious rats. J Clin Invest
1995;96:132-40.

5. Houpt JB, McMillan R, Wein C, Paget-Dellio SD. Effect of glucosamine hydrochloride in the treatment of pain of osteoarthritis of the knee. J Rheumatol 1999;26:2423-30.

6. Drovanti A, Bignamini AA, Rovati AL. Therapeutic activity of oral glucosamine sulfate in osteoarthritis: a placebo¬controlled double¬blind investigation. Clin Ther 1980;3:260-72.

7. Barzilai N, Hawkins M, Angelov I, et al. Glucosamine-induced inhibition of liver glucokinase impairs the ability of hyperglycemia to suppress endogenous glucose production. Diabetes 1996;45:1329-35.

8. Russell AI, McCarty MF. Glucosamine in osteoarthritis. Lancet 1999;354:1641; discussion 1641-2 [letters].

9. Rovati LC, Annefeld M, Giacovelli G, et al. Glucosamine in osteoarthritis. Lancet 1999;354:1640; discussion 1641-2.

10. Reginster JY, Deroisy R, Rovati L, et al. Long-term effects of glucosamine sulphate on osteoarthritis progression: a randomised, placebo-controlled clinical trial. Lancet 2001;357:251-6.

11. Vaz AL. Double¬blind clinical evaluation of the relative efficacy of ibuprofen and glucosamine sulphate in the management of osteoarthritis of the knee in out¬patients. Curr Med Res Opin 1982;8:145-9.

These are the exercises – but check with your Chiropractor before you go wild.

McKenzie exercises for disc protrusion

Stand by, stand by: Lie face down with your hands under your shoulders in the press-up position. Focus on letting your low-back muscles relax and lightly tense up your gluts. Breathe normally. Typically this can take a couple of minutes.

Then: Slowly raise your shoulders off the ground until you are resting on your elbows. Let your low-back ‘sag’ with gravity to the ground. Hold this for a couple of minutes.

And then: If comfortable lift your shoulders up a little further and hold, and hold, and hold, and rest.

What’s it doing: Your pain should reduce and shrink towards the centre of your low-back, or ‘centralize’.

Here's great link to show you what I mean:
http://www.youtube.com/watch?v=wBOp-ugJbTQ

It stretches some of the muscles that compress the low-back and reduces the internal pressure of the disc by levering the disc apart and encouraging the contents of the disc to move back into the disc body.

Some don’ts though:
 • Don’t do them for 1 hour after getting up. Let gravity work on your discs and let them settle down.
• If you have been diagnosed with spondylolysis. But there will be some discomfort so work with this but don’t push through the pain, it’ll do you no good.

Zofie, our Clinical Hypnotherapist writes:

As a practicing Clinical Hypnotherapist I have worked with many clients presenting with sleep problems. These have ranged from clients not being able to get to sleep, to some individuals who have the ability to fall asleep but then wake during the night as well those suffering from terrifying nightmares. A number of clients presenting with such problems have suffered in this way for many years and arrive with little hope that I can help. As such it is often quite difficult to persuade people that insomnia and poor sleep patterns can be helped in a matter of days or weeks.

In my role as a therapist I firstly ask all sorts of questions relating to the sufferer’s lifestyle and daily schedule as well as probing into their stress levels and what stressors are present in their life. In every case in my experience, what the client is unwittingly doing on a day to day basis to keep the problem going has become apparent very quickly.
Sometimes a particular event can act as a trigger for the sleep problem and although the event is subsequently dealt with, unfortunately by this time the sufferer has got into the habit of not sleeping or not sleeping well. When facing this challenge alone, the habit can be incredibly hard to shift. For others there doesn’t appear to be a particular trigger although sometimes it is set off by progressively rising stress levels.

In either event, through obtaining help in managing stress levels, which is then backed up by suggestion work and guidance to help you break old habits, longstanding problems can be shifted quickly. For many individuals coping with a lack of sleep they are stuck in a difficult vicious cycle which can seem almost impossible to break without help; the fear of not sleeping ultimately leads to certain rituals or habits being formed which further serve to strengthen the fear and as a consequence, the problem.

Many sufferers will relate to the idea of the law of revered effect which states: “the harder you try the harder it becomes” and this is especially true for sleep! But it can be incredibly hard to stop trying when it has become habitual which is where intense relaxation and confidence building can help.

Hypnotherapy can help you to bridge the gap between the fear of not sleeping and breaking the mould thereby creating new and healthy sleep habits. If you would like help and advice on how to deal with a sleep disorder or anything similar please get in touch. I can be contacted on 0117 922 1542 and 07966 094 979.
Zofie
Clinical Hypnotherapist
DHP.HPD.MAPHP.MNCH
CBT Trained