ArizonaBackInstitute

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.

If you have ever read any of my previous blog posts or have seen some of the other articles I have written, you undoubtedly know where I stand on the chronic use of medications to deal with back pain. The fact is that medication use for back pain is unproven and it’s not substantiated by the medical literature. Not only that but, in many cases the intended use for the medication prescribed is not for back pain. A new and very dangerous player in the medication approach to back pain is the use of opioids, a very dangerous and highly addictive drug class.

Several recent reports have shown that the use of opioids for back pain has led to a serious increase in the number of injuries and deaths. The benefits of opiods in the long-term treatment of chronic back pain haven’t been documented, but the risks related to this treatment approach are painfully apparent.

In fact the National Drug Intelligence Center (NDIC) recently issued a publication showing that “the number of deaths and treatment admissions involving controlled prescription drugs, particularly prescription opiods, has increased significantly. This problem is becoming so wide spread that the Centers for Disease Control and Prevention (CDC) has reported that the #1 cause of death in middle-aged adults is no longer auto accidents, but is now drug poisoning. During 2005-2006, 92% of poisoning deaths involved drugs!

This is all very shocking to say the least…things have to change, and my hope is that many of you will find relief from your back pain without the use of drugs. Non-surgical treatments like spinal decompression really work. This treatment approach provides a long lasting benefit by addressing the cause, not clouding your brain so you don’t realize how bad you are. So the next time you reach for that pill bottle, do yourself a favor and call my office instead.

It’s obvious that smoking is bad for you, in spite of what some of the tobacco companies may have said in the past. And as a doctor, I feel it is my duty to at least mention the known effects of smoking to my patients that do so, to at least attempt to sway them a little. Everyone that I know that smokes, wishes they could quit, but they just can’t ever seem to pull it off.

As a back pain doctor I am always asked whether or not I believe smoking affects the spine, does it cause an increased likelihood of back pain? The short answer to that is yes, I do. But, medical studies on the subject just never could quite pin smoking down as a potential cause. It makes sense when you think of the physiology of the disc, the fact that it lacks a blood supply and relies on fluid exchange from the blood supply to the bones above and below. You would logically think that a lack of oxygen in the system would affect the tissues without a blood supply first, right?

Well, a Finnish study recently published in the American Journal of Medicine has come to the conclusion that smoking is “modestly” associated with the risk of low back pain and the effects may be “at least partly reversible.” The Finnish researchers identified and reviewed 81 studies from around the world involving smokers, former smokers, or never-smokers and low back pain conducted between 1966 and 2009. Of those, 40 studies involving more than 300,000 adults and adolescents met the standards for the analysis.

They found that “Current smokers (adolescents or adults) are at only 31% higher risk of low back pain compared with never smokers but this estimate is only for low back pain for one day or more during the past 12 months,”

The research does suggest “the effects of smoking may be at least partially reversible,” since former smokers were less likely to seek care for low back pain than current smokers. However, more research into former smokers will be needed to make a more definitive claim.

So there you have it, at least some evidence of a cause and effect relationship between smoking and lower back pain. I know it isn’t ground breaking research, but it’s all I have.

Two randomized controlled trials on vertebroplasty published in the New England Journal of medicine in August of 2009 came to some unexpected conclusions.The first study performed in the United States by David Kallmes, MD of the Mayo Clinic compared the vertebroplasty procedure to a sham procedure in 131 patients in 11 centers. The second study performed by Dr. Rachel Buchbinder of Monash University in Australia compared vertebroplasty to a sham procedure in 78 patients in 4 centers. Neither study found any advantage for the vertebroplasty procedure compared with the dummy procedure.

With the above findings from two independent studies in different countries you would think that there would be a significant decrease in the number of vertebroplasty procedures done in this country, right? Well not exactly, you see the doctors who perform vertebroplasty swear by it, no matter what the research says. Why would they do this? Because they have seen it work time and time again. In fact an article in the Boston Globe in response to these studies suggested that “these findings are unlikely to change the practice of many specialists, who said they don’t jibe with their years of experience”, which is what brings me to my point. Medical research is there as an aide to help doctors do the right thing, to do the best we can for our patients and offer those under our care treatments that are proven effective. Does this mean we don’t do anything that the research has yet to prove? I don’t think so.

Take into consideration spinal decompression, a treatment that has become more and more popular over the past several years. There are studies showing very good results and a high success rate, but opponents of the treatment claim that the research isn’t of high enough quality and there are no RCT (randomized clinical trials) proving it’s effectiveness. Does that mean it doesn’t work? Absolutely not, in fact I have seen it work on thousands of patients like clockwork. Over and over again, patients respond to spinal decompression, and in my program always after other treatments have failed. Now what if a study came out showing that it didn’t work, would I stop offering it? Not on your life!

I bring up this point because clinical experience in my opinion trumps medical research. An effective treatment for any condition is an effective treatment with or without peer reviewed journal articles. Most doctors who don’t have a vested interest appear to be scientifically minded and impartial until you start messing with their livelihood. In reality many aspects of medicine are not as scientifically grounded as you may think. Many of the routine procedures for back pain have not been proven or in some cases have been proven not work. Yet, they are still performed day in and day out.

Now am I saying we don’t need research? Absolutely not, I love research. I look forward to my monthly journals with anticipation. The good news is that a lot of the most recent studies on back pain and disc physiology are helping to support what I have seen in my practice over the years. That is a very satisfying feeling and one that hope helps a lot of back pain sufferers through the years.