Archive for year: 2015

If you haven’t read David Seamen’s clinical synopsis: The chemistry of discogenic and disc herniation pain, I highly recommend you do…its available on this site. As Chiropractors we are of course just itching to “lay hands on” our patients to find and “cure” them of their pains, mechanically. However a potential reality of discogenic pain, herniation in particular is the undeniable chemical influences perhaps driving the pain. He discusses the concept of the herniation being “turned on” by inflammation in the diet. The difficulty we face given these chemical realities is at what point do we conclude “dietary inflammation” not necessarily a “heal-able” mechanical lesion is predominant? And if we are co-treating at what point do we conclude which protocol did the work or was enough to actually “work” given the high improbability patients will follow our instructions? Will diet modification definitively stop episodes in the future? There’s no simple answer in my opinion however its’ apparent that many mechanistic-methods have substantively been able to give long-term relief (without mention of diet) and cultures whose daily physical labor and lack of sitting (and soda?) simply have less LBP disability. I have not seen any studies to date where extensive and exclusive “diet modification”, in exclusion of mechanical interventions and/or dedicated Core control exercise, was shown to substantially end LBP or sciatic, however we do know type II diabetics show an increased expression of HNP.

Many of us tend to associate LBP with the disc, more specifically with a ‘herniated’ disc. However research which began in the mid 1970s’ and was described in depth in the 1987 text Clinical Anatomy of the Lumbar Spine (Bogduk & Twomey) explicated the most compelling source of acute LBP: internal disc disruption promulgating annular ‘tears’. Not coincidentally these “tears” create a pain profile mimicking a ligament sprain.

Sato et al (Eur Spine 2005) further delineates this  likely mechanism of acute (non-radicular) LBP; a “re-reputure of a previously repaired region in the posterior annulus of a moderately degenerated disc with an annular tear”.

Torsional injuries along-side degenerative changes create circumferential tears, these tears typically do not change the outer architecture of the disc so direction-preference is absent and an often “unendurable” (discogenic) pain persists until slowly healed with granulation tissue (type III collagen).

Only ~10% show ‘leakage’ thru the tear.

Sato found nearly 50% of patients developed the acute LBP with “casual” movements…further validating the “weakened” annular fiber theory and susceptibility to torsional strains; the disc’s weak link.

Sarno’s groundbreaking books beginning in the early 1980’s put a ‘non-organic/non-structural’ spin on the impending epidemic of LBP in western culture. Instead of adding more ‘mistaken structural causes’ to the fields of physical medicine (trying to “explain” why back pain disables so many) he opted to consider TMS (tension myofascial syndrome). The underlying cause is assumed to be personality issues which drive physical alterations which produce pain. Such traits include:

• Having a strong inner drive to succeed
• Having a great sense of responsibility
• Being self-motivated and disciplined
• Being their own severest critics
• Being perfectionistic and compulsive

Dr. Sarno’s theory is that these personality characteristics interact with stressful life situations to cause the back pain. He points out that the source of psychological and emotional tension is not always obvious. Dr. Sarno’s theory of TMS describes a mechanism whereby emotional tension is pushed out of awareness by the mind into the unconscious. This unconscious tension causes changes in the body’s nervous system. These changes include constriction in blood vessels and reduction of blood flow to the various soft tissues, including muscles, tendons, ligaments, and nerves in the back. This causes a decrease in oxygen to the area as well as a buildup of biochemical waste products in the muscles. In turn, this results in muscle tension, spasm and back pain experienced by the patient. He contends the majority of patients will improve with ‘counseling’….a small percent require physical interventions which have no “real” impact but foster the patients placebo effect.

Recent reviews have pointed out that most of our treatment-techniques are likely based on individual ‘convictions’ vs. valid, widely accepted protocols i.e. established evidence. Through studies (of numerous types) data is collected then eventually synthesized into reviews; meta-analysis or systematic. Theoretically these reviews create as definitive a representation of the knowledge available as is possible. Many times our interventions feel the sting of the relative dearth of high-quality studies or perhaps less optimistically our procedures have difficulty demonstrating their superiority. In 2004 and 2007 Cochrane review summaries states:

“There was little or no difference in pain reduction or ability to perform everyday activities between people with LBP who receive spinal manipulation and those receiving other therapies”.

“Traction added to a PT regimen offered no additional benefit to those with LBP”.

 In 2010 a systematic review (Sportschaden Mar;24) concludes:

“For LBP spinal segmental stabilization is more effective than a minimal intervention but no more effective than any other PT intervention”.

Ann of Int Med Oct;2(14) 2007:

“There is good evidence for a moderate benefit to the use of heat for acute LBP”.

“Spinal manipulation shows fair evidence for a small benefit in acute back pain”.

“Chronic LBP & neck pain show moderate effect with cognitive behavior therapy, manipulation, acupuncture, massage & yoga”.