By Randall C Pruitt, DC, DACNB, DAAPM, MUAC, FACFN, CES-NASM
In my practice it is rare to see a patient with lower back pain or neck pain, not exhibit some other condition. Whether it be knee pain, shoulder pain or some other type of joint or muscle pain. However most doctors are so narrow in their focus that they rarely look past the body part wherein they specialize.
This is unfortunate for many reasons. Usually as the back or neck pain improves the other area will begin to affect the person much more significantly and a referral to another specialist is usually made. This can be a source of frustration for most people because who wants to go to an endless series of doctors and specialists when their problem could have been taken care of in one place?
A recent study by Michael Korff PhD and colleagues found that about 20% of the population of the United States has chronic spinal pain at any given time. And of this population 87% reported at least one other musculoskeletal condition. However, these problems are not only an accessory condition but, create about 1/3rd of the persons disability in conjunction with the spinal pain.
Another article written in the journal Pain by Peter Croft MD states that humans are vulnerable to multiple forms of pain, and common conditions will inevitably occur together.
Because of this common thread my team here at the Arizona Back Institute is very well trained in the treatment of a variety of musculoskeletal conditions, injuries to the knee, the rotator cuff and conditions like carpal tunnel syndrome and neuropathy just to name a few. Of course our main focus is on chronic spinal conditions, but my philosophy is that their affect on other areas should be treated as part of the total injury and not as a separate case, requiring a referral.
If you have suffered from lower back or neck pain for any length of time, you may have been given facet joint injections as a part of your treatment. Facet joint injections, are injections into the joints of the spine with a steroid to relieve pain. The theory behind these injections appears sound, since these joints are highly innervated with pain sensitive nerves, it would appear that injections would help. The second step in the injection process is to then ablate or deaden the nerves in the joint to prolong the pain relief. These nerves do however, grow back usually within 3-6 months.
While the rationale behind these injections makes some sense the medical research shows them to be ineffective. In fact several studies have come to the same conclusion, that essentially these injections are no better than a sham injection and do not give the patient any semblance of a long term result.
The problem however with any study is that the treatment is often applied to a more generalized group, lower back pain in this example. What needs to happen in order to give us better clinical indications is to break down the patients by diagnosis and treat only those who fit the criteria. that way the true success rate can be established.
In my own practice we are very meticulous in our selection process and patients are not accepted into any program unless we have been able to establish very specific clinical findings. That is why our success rate is so high, we only accept those we feel very strongly that we can help. Unlike many medical studies published apparently disproving individual treatments, where the study population is a mixed bag.
The truth is no one treatment has all the answers. In my experience the best treatment approach is one that addresses all of the various components of back and neck pain and treats them simultaneously, giving the patient the best possible chance of a successful outcome. That is what we strive for everyday at the Arizona Back Institute.
By Randall Pruitt, DC, DACNB, DAAPM, FACFN, MUAC, CES-NASM
With the unemployment rate at record numbers more and more people are out of work and willing to do whatever they can to make money to support their families. With that said there is not a day that goes by that I don’t give thanks to my choice of careers and the impact that choice has on so many others.
Everyone wants to hear that they have done a good job, no matter what the vocation or job description. It gives you a sense of satisfaction and pride to know that others see your hard work and dedication. My job as a back pain doctor is no different. My acknowledgment of a job well done is a patient responding to my care, someone who has suffered, but now is pain free.
I have had this conversation many times with my employees when they comment on the complete 180 degree turnaround of a particular patient. Often we’ll see someone literally become a different person, they are cheerful, friendly and really happy in sharp contrast to the miserable, edgy, skeptical person they came in here as.
Just today Francesca my front office coordinator told me about a patient of ours who after 20+ years in pain turned around as he was leaving the office and said to her ” You guys have no idea how much you have changed my life”. This patient went through our manipulation under anesthesia program and I can’t tell you how satisfying it is to hear a patient say that. With the programs we offer, treatments like manipulation under anesthesia and spinal decompression we hear comments like that a lot. Our programs have helped those that everything else has failed. In fact our average patient has been in pain for 7.8 months and has tried no less than 3 other treatments and we get them better!
And that is why I love my job…
Pain is a much more complex issue then we think. No one likes to be in pain and back pain can really affect your life in so many ways. The problem with pain is that not only does it affect the areas of your body involved (like your back) but it also has a very significant impact on your brain making it a much more difficult issue to deal with.
Research done by A. Vania Apkarian, PhD and colleagues showed that chronic back pain has a strong effect on the prefrontal cortex in humans. The newest research reveals that this connection is much more powerful then we once thought. Evidence shows that chronic pain alters the structure of the brain leading to destructive atrophy of regions involved in memory, rational thinking, and the processing of emotions. They’ve also showed that long term neurological changes associated with chronic low back pain may result in impairments in thinking and decision making.
So as you can see, back pain is much more debilitating then you may have thought. It affects not only function, but also emotional well-being, concentration and decision making. Dealing with the pain, needs to be done through restoring the structures of the spine, not masking the perception of pain with drugs. Also if pain has this type of effect on the brain, imagine what affect the surgical removal of tissues from spine or a fusion of the spinal segments has on the brain.
Just look at the example of a person losing a limb. That limb had a connection to the brain and information from that limb activated brain centers and wired the brain a certain way, depending on the skills that the person could perform with that limb (ie like playing the piano). Remove the limb and the brain immediately undergoes dramatic change, and at times the person may still get the perception that the limb is still there (phantom limb pain). The spinal joints and muscles are rich in receptors and have a large influence on brain function. Damage or alteration of these structures leads to more and more dysfunction as these studies have shown.
Treatments like neurologically based spinal rehabilitation, spinal decompression and MedX rehabilitation address chronic back pain from the structural perspective and allow functional restoration of the problem. This leads to changes ultimately at the brain level and an improvement in the deficits that the chronic pain may have caused. Drugs and invasive treatments don’t do this.
One of the questions I receive on an almost daily basis has to do with the difference between spinal traction and spinal decompression. Although the mechanisms seem very similar there really is a very important difference. You see, when the spine is pulled in a traction type fashion the muscles of the spine actually react. They react by engaging and contracting to protect the delicate spinal cord and nerves. This protective mechanism is important, however not therapeutic to the disc because the pressures inside the disc don’t change and in some case they actually increase. True spinal decompression offers a very unique application in that as the spine is pulled there is feedback through a computer system that monitors the muscles guarding response. As the muscles engage the computer system backs off the pull and through a very sophisticated process the contraction is gently overcome. This leads to reproducible and consistent negative pressures inside the disc allowing an influx of nutrition and a decrease in bulging or herniated material. A very significant difference when compared to simple traction.
The above explanation is exactly why a recent study presented at the 2009 annual meeting of the International Society for the Study of the Lumbar Spine is very misleading. According to researchers from the Netherlands spinal decompression doesn’t work, and here is how they came to that conclusion. They took 60 patients that met the following criteria 1) they had low back pain of more than 3 months 2) they had radiographic evidence of a degenerative disc 3)or MRI evidence of a bulging disc. Every study subject was prescribed a course of physical exercise and then randomized into one of two groups: 1) 20 sessions on a machine marketed as a spinal decompression device and 2) sham spinal decompression which essentially was just static traction. The study subjects were blinded as to what treatment they received.
The researchers did find that the patients treated with the “spinal decompression” device in fact did have tremendous success. Their pain levels went from a 61 at baseline on a visual analog scale to 32 at the 14 week follow-up, there was also improvement in leg pain, Oswestry Disability Index Scores improved and there was a significant reduction in the use of pain medication. However, there was similar improvement in the sham group so the researchers came to the conclusion that spinal decompression doesn’t work. An interesting conclusion to say the least, now here’s my take on the study…
First, to be clear there was significant improvement in both groups. We all know the placebo effect is very powerful and if you recall from one of my previous blog posts there were similar results with vertebroplasty. A much more invasive and potentially dangerous treatment, but doctors wouldn’t accept the results. Why? Because they saw with their own eyes the clinical benefits in their offices on a daily basis. Another problem with this study is the machine used as the spinal decompression machine in my opinion isn’t spinal decompression, it was intermittent traction. And the only difference between both groups was that one was static (the sham group) and was was intermittent (meaning the table would pull on the spine with a relaxation in between). So essentially they were comparing traction to traction. My advice…have a third group utilizing either the VAX-D or the DRX9000 the only real spinal decompression devices on the market in my opinion.
So the bottom line, spinal decompression works and it works very well, especially on patients that have not responded to other treatments and are moving into a chronic situation. It’s safe and in my experience it is the best treatment for disc related low back and neck pain available today.
