The most common cause of low back pain is faulty Spinal Biomechanics. The sacroiliac joints and their symmetrical function are key to normal back function. The diagram above demonstrates the central point of center of gravity and the normal figure of eight range of motion. If one of the pelvic joints(SI) joints gets restricted, (often on the right) The range of motion shift will cause increase stress and strain on the lumbar joints(facets). This overload will cause inflammation/pain and eventually joint overload that can lead to Osteoarthritis(OA).   Adjusting the SI joints back to normal function will treat one of the major causes of  Low Back Pain. It usually takes a series of 6-8 adjustments to begin the process of  restoring  normal motion. Muscle strengthening and balancing exercises are then implemented. The typical presentation for mechanical low back pain is for the patient to wake up with pain and stiffness and the pain subsides as standing and movement dissipates the accumulated fluid in the joint capsules.  Quick movements, twisting motions, and lifting can exacerbate the pain and trigger painful muscle tightening and spasms.

In 2005, subluxation was defined by the World Health Organization as "a lesion or dysfunction in a joint or motion segment in which alignment, movement integrity and/or physiological function are altered, although contact between joint surfaces remains intact. It is essentially a functional entity, which may influence biomechanical and neural integrity."

Over time, the tendons (that hold muscle to bone) and ligaments (that hold bone to bone) can actually start pulling the bone from where it should be, creating bone spurs. Bones will conform to any pressure applied to them. As these bone spurs grow and form, they will sometimes impinge on a nerve causing the pain and debilitating symptoms.

Bone spurs that form along the spinal column of your neck or back can lead to Nerve impingement causing severe pain, restricted movement, radiating arm and leg pain, weakness in the extremities, numbness and, in some cases, disability.

Chronic Overweight, and increased Lumbosacral Disc Angle. Ideally is should be ~ 32 Degrees.  Any increase will increase load on the L5/S1 facets, as seen below.

Chronic Bone Spurs can lead to Nerve Root damage and referred Leg Pain.

More Dermatome research found at bottom of this page.

Non-surgical Treatment for bone spurs causing nerve impingement include

medications such as anti-inflammatories, muscle relaxers and pain medications. Cortisone injections can provide temporary relief. Physical therapy and exercise can strengthen the muscle around the area and correct muscle imbalance. Chiropractic care adjusting and mobilizing the  motion segments above and below the hypermobile segments  will  prevent and minimize  the cause of the Bone Spurs.

Typical surgical treatments involve massively invasive surgery, requiring many months of recuperation and a less than 50% chance of success. Read below about the poor results of surgery.

"ABOUT IMAGING STUDIES FOR LOW BACK PAIN

• Experts consider imaging studies to be overused in the evaluation of patients with acute low back pain. The vast majority of patients with nonspecific low back pain have no identifiable cause.

• Fewer than one percent of radiographs find the cause of a case of low back pain.

• Patients given recommended care (no radiograph) experience no difference in health outcomes compared to those given lower back radiographs, other than patient satisfaction.

• Disc protrusions detected by X-rays are often blamed for low back pain, but disc protrusiare rarely responsible for the pain, and surgery seldom alleviates it.

• CT and MRI studies do not identify where pain is located, except in patients where specific disease is suspected."

The above is quoted from the National Committee for Quality Assurance (NCQA), State of Health Care Quality, 2007, p. 45. The original document is available at no charge at:

http://tinyurl.com/28xe9x

Mitch Miglis, DC, Cert. MDT

Richard Deyo, MD, MPH, who wrote about the fallacy of the disc theory:

“Early or frequent use of these tests [CT and MRI] is discouraged because disc and other abnormalities are common among asymptomatic adults…Degenerated, bulging, and herniated discs are frequently incidental findings…Detecting a herniated disc on an imaging test therefore proves only one thing conclusively: the patient has a herniated disc.” He concludes that 97% of back pain is “mechanical” in nature, and disc abnormalities account for only 1% of back problems. [11]

[11] Deyo RA et al. Spinal-fusion surgery -- the case for restraint, N Engl J Med, 2004; 350:722-6. [11] Deyo RA et al. Spinal-fusion surgery -- the case for restraint, N Engl J Med, 2004; 350:722-6.

Non-surgical treatment for bone spurs causing nerve impingement include

medications such as anti-inflammatories, muscle relaxers and pain medications. Cortisone injections can provide temporary relief. Physical therapy and exercise can strengthen the muscle around the area and correct muscle imbalance. Chiropractic care adjusting and mobilizing the  motion segments above and below the hypermobile segments  will  prevent and minimize  the cause of the Bone Spurs.

Typical surgical treatments involve massively invasive surgery, requiring many months of recuperation and a less than 50% chance of success. Read below about the poor results of surgery.

"ABOUT IMAGING STUDIES FOR LOW BACK PAIN

• Experts consider imaging studies to be overused in the evaluation of patients with acute low back pain. The vast majority of patients with nonspecific low back pain have no identifiable cause.

• Fewer than one percent of radiographs find the cause of a case of low back pain.

• Patients given recommended care (no radiograph) experience no difference in health outcomes compared to those given lower back radiographs, other than patient satisfaction.

• Disc protrusions detected by X-rays are often blamed for low back pain, but disc protrusiare rarely responsible for the pain, and surgery seldom alleviates it.

• CT and MRI studies do not identify where pain is located, except in patients where specific disease is suspected."

The above is quoted from the National Committee for Quality Assurance (NCQA), State of Health Care Quality, 2007, p. 45. The original document is available at no charge at:

http://tinyurl.com/28xe9x

Mitch Miglis, DC, Cert. MDT

Dr. Deyo, in his book, “Hope or Hype: The obsessions with medical advances and the high cost of false promises,” mentions the sentiments of ethical spine surgeons:

“Some surgeons, like Dr. Edward Benzel at the Cleveland Clinic Spine Institute, believe that too much spine fusion surgery is being performed. Benzel estimated to the New York Times that less than half the spinal fusions being performed were appropriate. ‘The reality of it is, we all cave in to market and economic forces,’ he was quoted as saying, adding that the current system of paying doctors is ‘totally perverted.’ Dr. Zoher Ghogawala, a Yale neurosurgeon, agreed that too much fusion surgery is done, saying, ‘I see too many patients who are recommended for fusion that absolutely do not need it.’”[14]

The battle over your aching back

New alternatives to surgery are gaining favor. Here's a look at the best treatment options.

By Matthew Boyle, Fortune writer

August 25 2006: 5:48 PM EDT

(Fortune Magazine) -- John Chiota was ready to try just about anything. After a 2001 car accident, Chiota, a 63-year-old Connecticut lawyer and probate judge, had lower back pain so bad that he often had to hear cases while standing up. Simple tasks like shaving were agony. Physical therapy didn't help. Painkillers worked for a while but then wore off.

His doctors suggested surgery but could not guarantee that it would help. Chiota was about give the local acupuncturist a call when he heard about Norman Marcus, a psychiatry and anesthesiology professor who runs a small, private - and controversial - pain institute in Manhattan. "I knew it was off the beaten path," Chiota recalls, "but at that point, I didn't care."

Ten days after seeing Marcus and submitting to his therapy, in which he uses a needle to break up knotted muscle tissue - "trigger points" - Chiota was pain-free. Still, he admits Marcus is not for everyone. "He is not a quack, but he's not mainstream," Chiota says. "There are not a whole lot of guys like him."

Maybe not, but the ever-growing ranks of back pain patients have more alternatives to surgery than ever before. That's a good thing, since more than 70% of adults - including hordes of desk-bound business executives - will have back pain at some point in their lives; it's the second most common reason for doctor visits in the U.S., according to the National Ambulatory Medical Care Survey. In 2001, the World Health Organization declared lower back pain an official epidemic.

It's a costly one. A Duke University study found that treating back pain costs Americans more than $26 billion a year, or 2.5% of our nation's total health-care bill. Much of that spending is devoted to the 10% or so of back patients who suffer from chronic, debilitating pain, like Chiota.

For those poor souls, determining the precise cause of their pain is a frustrating maze of X-rays, MRIs, and CT scans. That's because the anatomy of the lower, or lumbar, spine - an intricate assemblage of bone, muscle, nerves, shock-absorbing disks, and ligaments - is much more complex than, say, that of the knee or hip. In a structure so complicated, there are a lot of things that can go wrong.

Pain in the lower back can result from multiple factors: mechanical, neurological, even psychological. Which helps explain why in a shocking 85% of cases, according to one researcher, doctors can't pinpoint why a person hurts.

There's still no proven consistent way to treat chronic lumbar pain, although there is a growing consensus against invasive, expensive surgery - and it's one shared even by some surgeons. Still, there's plenty of debate and confusion out there and any back pain sufferer trying to pick his way through the rival camps of surgeons, doctors, chiropractors, physical therapists, and pain specialists needs all the advance intelligence available. The following is a field guide to the kinds of professionals patients are likely to meet in their quest for relief.

As representatives of the various camps, we'll meet four medical men, each of whom has dedicated his life to a different treatment method. At the outer limits of the back world are people like Marcus, loved by his patients, but denounced by fellow MDs.

Orthopedic surgeons and chiropractors make up the standard approach - although chiropractors themselves were not long ago regarded as charlatans by the medical establishment and even now, many MDs do no more han tolerate them.

Trying to make sense of all these competing treatments and theories is a surgeon and researcher at Dartmouth, James Weinstein, who is leading the biggest-ever U.S. study of back surgery. His intention is to finally come to some definitive conclusions about what really works and what doesn't. He's finding, however, there are more forces than just mere science driving the battle over how to heal your back.

On Sept. 26 in Seattle, two thousand members of the North American Spine Society (NASS) will gather for its annual meeting. A boring affair, one would guess, replete with tedious recitations of arcane medical studies, tall tales from the golf course, and rubber chicken.

Think again.

This year's confab will feature the unveiling of early results from a massive six-year, $13.5 million study, conducted coast to coast in 12 locations and funded by the National Institutes of Health (NIH). The study, dubbed SPORT (Spine Patient Outcomes Research Trial), seeks to answer the most vexing question in back pain treatment: To cut, or not to cut?

Heading the study is Weinstein, chairman of the department of Orthopedic Surgery at Dartmouth's Medical Center and editor-in-chief of the journal Spine. He's also an advocate of nonoperative back treatment, and thus is something of a pariah among many of his fellow surgeons.

That doesn't bother Weinstein. What does bother him, he says, is that when "a patient puts his spine in my hands," he cannot say what results to expect. "We have failed in this basic principle."

Back surgery's frequent failure

Saying that back surgery can be a roll of the dice is not far from the truth. Last year there were 1,175,000 inpatient spinal surgeries in the U.S. alone, according to market research firm Spinemarket and newsletter Orthopedic Network News.

The best surgeons claim that 80% of their cases are successful, but "success" is a pretty nebulous concept. Most surgery patients still have some pain postoperatively. Failure is so common, meanwhile, that a term, "failed-back-surgery syndrome," has been coined to account for it.

Who's to blame?

On one side are surgeons who are too quick on the trigger. "Lots of back operations continue to be done with a shotgun approach," says Edward Hanley, chair of the Department of Orthopedic Surgery at Carolinas Medical Center in Charlotte.

But the desire of surgeons to operate is only part of the problem. The severity of chronic back pain leads many long-suffering patients to eschew conservative treatment and seek a quick fix in the operating room. "Patients' expectations these days are very, very high," says NASS president Joel Press.

To try to ground those expectations in hard data, SPORT's research team has recruited some 2,500 patients to gauge the efficacy of surgical vs. nonsurgical treatment for three common back disorders. The fireworks started early. "The SPORT study seems to announce a preconceived bias against operative care," wrote the NASS board of directors in 2003. Their major beefs regarded patient-selection criteria and the clinical design of the project, "which inappropriately favored nonoperative treatment," according to the American Association of Neurological Surgeons.

"It's the first time that I am aware of that people have criticized a study before it came out," says Weinstein. "I didn't expect that."

He should have. Tangling with spine surgeons can be hazardous to your health. In the mid-1990s, when the federal government tried to issue guidelines for treating acute back pain, the surgeons complained loudly. Sofamor Danek, a medical-device company (now part of Medtronic (Charts)), even sued to suppress the recommendations.

"Some companies are afraid of the results of [SPORT]," says Frank Phillips, an torthopedic surgery professor at Rush University Medical Center in Chicago. Weinstein admits that he was "naive" about the fact that "there are other interests at stake."

In June, Weinstein released the first set of SPORT data, for herniated-disk procedures, at a meeting of the International Society for the Study of the Lumbar Spine in Norway. To the relief of the surgeons, the data supported surgery for the ailment. "I don't care what the results are," Weinstein says. "What I am really interested in is the truth."

But if there is - arguably - too much back surgery in general, the conventional medical wisdom has shifted away from the knife somewhat in recent years.

Launched in 1978, the Texas Back Institute represents the establishment approach to treating back pain, one that has evolved to encompass a host of disciplines. In its early days TBI had just three surgeons and nine employees, but today its 204 staffers include physiatrists, psychologists, pain specialists, chiropractors, and physical therapists. Every year TBI handles more than 55,000 patient visits, and its 11 surgeons perform about 2,000 surgeries. (That may sound like a lot, but only 11% of TBI's patients actually go under the knife.)

The man minding this one-stop shop for back care is president Richard Guyer, a surgeon and one of TBI's three co-founders. TBI's soup-to-nuts approach to back treatment makes sense - if the chiropractor can't help you, he'll send you down the hall to the pain specialist, or maybe to the psychologist for some hypnotherapy. Surgery is a last resort. (One procedure done at TBI involves implanting artificial disks.)

But the setup also exposes the rifts that exist between various camps, including those forced into uneasy alliances. For instance, one minute a TBI chiropractor is praising spinal-decompression therapy, a new treatment - inspired by NASA - that involves reducing pressure on the spine to heal the spongy disks that sit between the vertebrae.

The next minute, a TBI surgeon derisively dismisses the technique. If these guys are together in one big tent, it's only because none of them can claim to have a proven solution. Guyer is realistic and even humble about that state of affairs. "Back pain is an enigma," he says. "We do the best we can."

If TBI is a back-repair department store, chiropractor Doug Seckendorf's Manhattan practice is a high-end boutique. Seckendorf's clientele includes Blackstone Group co-founder Pete Peterson and, reportedly, KKR kingpin Henry Kravis and former Treasury Secretary Robert Rubin - people who cannot afford to be laid up for weeks after back surgery. (Seckendorf's staff even makes house calls in the Hamptons.)

Complementary medicine can reduce pain

Twenty-two million Americans see chiropractors each year, and it can be effective in relieving acute pain. The mainstream medical community has grudgingly come to accept it - TBI, for example, added chiropractors nine years ago. But some older MDs still think it's quackery, mindful of a few overeager chiropractors who once claimed to be able to cure everything from diabetes to cancer.

Seckendorf makes no such rash claims. His practice, Manhattan Sports Medicine, includes nutritionists and massage therapy, but the bulk of the work takes place on his $15,000 chiropractic tables. "We're intense," he says. "We put you on a table and pull you apart."

Clients also sweat through workouts in a small gym under the guidance of exercise physiologists. For this they pay $450 for an initial visit, and $155 after that. Seckendorf doesn't accept insurance, but his rich clientele doesn't seem to mind.

Nearly a decade ago, Pete Peterson started having a good deal of back pain. An MRI test found spinal stenosis, a narrowing of the canal the spinal cord runs through, and an orthopedic surgeon recommended surgery. Seckendorf says this rush to judgment is common: "There's a fair amount of impulse buying in spine surgery, where the patient just wants to be out of pain."

But Peterson was no impulse buyer. What if surgery didn't work? "What a horrible scenario," he recalls thinking. A colleague told him about Seckendorf, who prescribed painkilling shots and physical therapy - a plan Peterson's surgeon had neglected to mention. Peterson tried it and was thrilled with the results. He calls Seckendorf his "principal advisor" when it comes to his back - an endorsement that's sure to bring more well-heeled clients through Seckendorf's door.

Chiropractors like Seckendorf are entirely respectable these days. Norman Marcus, however, is not. When he was asked to speak about back pain to orthopedic surgeons at Lenox Hill Hospital, where

he started a pain treatment center in 1983, he didn't expect a warm welcome.

Marcus was not an orthopedist or a neurologist - his training was largely in psychiatry. "It was hard to imagine that someone with my background would have the answer," he recalls.

At the lectern, Marcus said that the reason back pain remained so intractable was the medical community's failure to look at anything outside the vertebrae, disks, and nerves as the cause of pain. "We need a more comprehensive approach," he recalls saying. "Surgery isn't a good idea." Some surgeons shouted him down, while others walked out.

Although Marcus remained at Lenox Hill until 1997, he was persona non grata. But by then he had received his true calling from a doctor named Hans Kraus, who gained notoriety as both a daring rock climber and as President Kennedy's back guru.

Kraus, then 85, and Marcus met in Manhattan in 1991. Over lunch, Kraus asked Marcus what he did for a living. "I manage pain," Marcus said. "Why don't you get rid of it?" Kraus asked. For the next five years Kraus taught Marcus his approach, which posits that muscles are the source of chronic pain. Kraus used his hands to probe for trigger points - muscles that were seizing up, say, due to injury--and then plunged a long needle deep into those spots to break them up. (This is followed by physical therapy.)

Unlike acupuncture, which uses small needles to balance the body's "energy pathways," Kraus's treatment is more direct. "It's how a porcupine is different from a peach," Marcus says. But like acupuncture, Kraus's approach, championed by Marcus since Kraus's death in 1996, has never been accepted by the medical establishment. (One well-known surgeon calls it "magic.")

Marcus thinks he knows why: "There's no money in it," he says conspiratorially over dinner at a local trattoria. Back surgery is big business: The market for implants and devices used in back surgeries grew 22% last year, to over $4.2 billion, according to Spinemarket and Orthopedic Network News.

While a spinal fusion (basically bolting two vertebrae together) can cost upwards of $40,000, a session with Marcus runs $420. And in Marcus's tranquil Midtown office "there's no hardware, nothing to sell," he says. Yet. Marcus is developing a hand-held battery-powered device that will more accurately identify trigger points. If it works, Marcus will get a stake in a company that will market the device to physicians.

Marcus won't be in attendance when James Weinstein releases his SPORT data in Seattle later this month, but he'll be watching closely. Data that support nonsurgical treatment, after all, could bring more patients his way. A few blocks uptown, Seckendorf would welcome such findings as well. And Guyer? All he'll say is that SPORT is sure "to answer some questions." But as those answers, whatever they are, trickle in, the battle for your back will continue to rage.

From the September 4, 2006 issue

 

 

Find this article at:

http://money.cnn.com/magazines/fortune/fortune_archive/2006/09/04/8384724/index.htm

Back Pain

Back Pain and Chiropractic:

"...patients suffering from back and/or neck complaints experience chiropractic care as an effective means of resolving or ameliorating pain and functional impairments, thus reinforcing previous results showing the benefits of chiropractic treatment for back and neck pain."

Source: Journal of Manipulative and Physiological Therapeutics, Verhoef et al. (1997)

"...for the management of low-back pain, chiropractic care is the most effective treatment, and it should be fully integrated into the government's health care system."

Source: The Manga Report (1993)

In the past year over 75% of Americans had back problems. Almost two thirds of those patients were more satisfied with chiropractic therapies than the care given by a medical doctor. Seventy percent of Americans feel it is important to include chiropractic in their health care plan. ACA's Booklet, American Perception of Practitioners & Treatments for Back Problems - A team of researchers has identified a catch-22 of lower back pain. Those with lower back injuries can worsen their pain by avoiding using hurt muscles. Other muscles, including those in the abdomen or on the sides of the torso, contort to compensate, leading to greater pressure on the spine and damaging discs.

Source: 2004 Dr. Joseph Mercola.

Back Pain Is The Leading Cause Of Limitation!

According to the National Institutes of Health (Harris et al. 1999), lower back pain is one of the most significant health problems in the United States, with back pain being the most frequent cause of activity limitation in people younger than 45 years of age: 65-80% of all people have back pain at some time in their life.

Source: 1995-2004 Life Extension Foundation.

Researchers state of the 300,000+ spinal disc surgeries as many as 90% are unnecessary and ineffective
Source: Finneson BF. A lumbar disc surgery predictive score card: a retrospective evaluation," Spine (1979): 141-144

Annual costs of back pain in the U.S. range from $20 to $75 billion, and as much as $100 billion worldwide.
Source: Bigos S, et al. Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14. Rockville, MD: U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Dec. 1994
It is estimated that more people see chiropractors for back problems than for all other ailments combined. Chiropractic spinal manipulation has been recognized by the U.S. Agency for Health Care Policy and Research as an effective therapy for acute low-back pain. Chiropractic treatment has been found to be more beneficial to patients with persistent back and neck complaints than other forms of manipulation. Research in Great Britain found chiropractic to provide "worthwhile, long-term benefits" for patients with low back pain in comparison to hospital outpatient management. This study also found chiropractic benefits to persist for a three-year period, indicating long-term benefits. For patients with uncomplicated, acute low back pain, chiropractic has also been found to be effective. A cost comparison study of back-related injuries showed the number of work days lost for patients treated with chiropractic to be nearly ten times less than that of patients treated under medical care. Also, average compensation costs for chiropractic care were $68.38, compared to $668.39 for patients treated with standard, non-surgical treatments.

Source: 1998-2004 ICBS, Inc.

Low Back Pain Facts

80-90% of all adults will suffer with low back pain some time in their life.

Low back pain is the leading cause of disability for people under 45 years of age.

Annual costs of back pain in the U.S. range from $20 to $75 billion, and as much as $100 billion worldwide.
Source: Bigos S, et al. Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14. Rockville, MD: U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Dec. 1994
It is estimated that more people see chiropractors for back problems than for all other ailments combined. Chiropractic spinal manipulation has been recognized by the U.S. Agency for Health Care Policy and Research as an effective therapy for acute low-back pain. Chiropractic treatment has been found to be more beneficial to patients with persistent back and neck complaints than other forms of manipulation. Research in Great Britain found chiropractic to provide "worthwhile, long-term benefits" for patients with low back pain in comparison to hospital outpatient management. This study also found chiropractic benefits to persist for a three-year period, indicating long-term benefits. For patients with uncomplicated, acute low back pain, chiropractic has also been found to be effective. A cost comparison study of back-related injuries showed the number of work days lost for patients treated with chiropractic to be nearly ten times less than that of patients treated under medical care. Also, average compensation costs for chiropractic care were $68.38, compared to $668.39 for patients treated with standard, non-surgical treatments.

Source: 1998-2004 ICBS, Inc.

Low Back Pain Facts

80-90% of all adults will suffer with low back pain some time in their life.

Low back pain is the leading cause of disability for people under 45 years of age. Annual costs of back pain in the U.S. range from $20 to $75 billion, and as much as $100 billion worldwide.
Source: Bigos S, et al. Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14. Rockville, MD: U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Dec. 1994
It is estimated that more people see chiropractors for back problems than for all other ailments combined. Chiropractic spinal manipulation has been recognized by the U.S. Agency for Health Care Policy and Research as an effective therapy for acute low-back pain. Chiropractic treatment has been found to be more beneficial to patients with persistent back and neck complaints than other forms of manipulation. Research in Great Britain found chiropractic to provide "worthwhile, long-term benefits" for patients with low back pain in comparison to hospital outpatient management. This study also found chiropractic benefits to persist for a three-year period, indicating long-term benefits. For patients with uncomplicated, acute low back pain, chiropractic has also been found to be effective. A cost comparison study of back-related injuries showed the number of work days lost for patients treated with chiropractic to be nearly ten times less than that of patients treated under medical care. Also, average compensation costs for chiropractic care were $68.38, compared to $668.39 for patients treated with standard, non-surgical treatments.

Source: 1998-2004 ICBS, Inc.

Low Back Pain Facts

80-90% of all adults will suffer with low back pain some time in their life.

Low back pain is the leading cause of disability for people under 45 years of age

2010  Paper “Safety of SMT”

An interesting paper (in press) describes adverse events after manual therapy (1). The authors conduct a systematic review of mild, moderate and severe adverse events after manual therapy.

While they define manual therapy broadly as "any techniques administered manually, using touch, by a trained practitioner for theraputic purposes", the RCT arm of their review contained mostly thrust manipulations. They review only prospective cohort studies (8 in number) and RCT's (31 in number) and exclude case reports, letters, etc. Techniques delivered by "mechanical, automated, electronic or computer" aides were excluded.

The review finds that "nearly half of patients after manual therapy experience adverse events that are short-lived and minor". Most of these adverse events are within 24 hours of the treatments and resolve within 72 hours and are most likely following the initial treatment.

The risk of major adverse events is very low, "lower than that from taking [the relevant] medication" for the condition. The authors therefore suggest that risk be assessed in context, since all health care interventions contain inherent risk. Here are some take home points cited by the authors:

1. Risks for adverse events after manual therapy were about the same as for exercise.

2. Risks for adverse events after manual therapy were greater than for GP/"usual care".

3. Risks for minor/moderate adverse events after manual therapy (HVLA thrust, in this case) were greater for medications.

4. Risks for adverse events after manual therapy were the same as for sham treatments.

5. Cited risks by the authors:

a. Risk from NSAID death for OA 100-400x greater than manual therapy.

b. Lumbar manipulation 37,000-140,000 safer than NSAIDs and 55,500-444,000x safer than surgery for disc herniation.

c. Cauda equina syndrome 7,400-37,000x more likely to result from surgery than from spinal manipulation.

Using statistical methods of estimation to extrapolate from available data, the authors estimate the upper 95% confidence limit for risk of a major adverse event from manual therapy as about 0.003%. No reports of strokes or cervial artery disections specifically from cervical manipulation were reported in any of the studies which qualified for review. The meaning of the latter should be tempered by the extremely rare nature of such events (good news and bad: Good news: such events are exceedingly rare; bad news: While rare, they are understudied, poorly understood and catastrophic). Unfortunately, the authors did not sub-group risk assessment by spinal region.

Considering the above findings, it might be interesting to ask the following questions:

1.How many on this list counsel patients about adverse events before, or after, the first manual treatment, either as part of informed consent or otherwise?

2. If informing patients about this possibility, how is this phrased and are any actual data used, such as above?

3. What is the general clinical impression of adverse events after manual therapy and can you grade your experience (subjectively, of course; unless you have actual data) into mild, moderate and severe reactions (using commons sense meanings)?

4. Do you feel that adverse events are under-reported, over-reported or "just right" (the Goldilocks question), in the literature?

Regards,

Mitch Miglis, DC, Cert. MDT

1. Carnes, D, et. al., Adverse events and manual therapy: A systematic review, Manual Therapy (2010), doi:10.1016/j.math.2009.12.006

 
Dermatome Research:

Did you know that most of the dermatome charts that are floating around the internet and on the walls of doctors' offices were based on investigations made over 35 years ago at best (31), and over 90 years ago at worst(30). Heck, some investigation date back to the 1800s (32)! Although in 1948 Keegan et al. had the right idea for developing dermatome charts (33), in that he studies and mapped the effects of disc herniations on the skin in the extremities, his results still couldn't confirm any of the prior work!

Kortelainen et al: In 1985, Kortelainen et al. (1) conducted an investigation into the 'pain referral patterns' (dermatomes) and neurological findings prospectively in 403 patients who were about to have a discectomy. CT results and surgical results (confirming compressive disc herniation) were compared with those patients pain referral zones. They discovered that spinal nerve root irritation (via disc herniation) did NOT always correlate with the anticipated pain referral zones as classically described. This was especially true of the S1 dermatome. Here is a table of what they found:

In summary, the pain projection into the L5 dermatome was caused by L5 nerve root compression in 79% of the cases, and by L4 nerve root compression in 21% of the cases; pain project in into the S1 dermatome was caused by S1 nerve root compression in only 56% of the cases, and by L5 nerve root compression in 44% of the cases! As you can see by these results, S1 dermatomal pain (pain in the side of the foot and little toe) is not very accurate at predicting the level of nerve root compression/irritation. (1) In closing they noted the the high disc herniations (L3/4) were not predictive of any expected neurological pattern. (I would note that the Kortelainen study was not as 'scientific' as the up-coming Nitta study, and we can only assume that the disc herniations all caused compression of the traversing spinal nerve root and NOT the exiting spinal nerve root. (There was no mention of this very important factor in the paper!)

Nitta et al: Finally, Nitta et al. published the first investigation that was of high scientific design (2)! In 1992, this group of investigators successfully mapped the sensory-dermatomal distribution of the L4, L5, and S1 nerve roots. They gathered 71 patients, who were suffering disc herniation-associated radicular pain, and 'blocked' (anesthetized) their problematic nerve root with Xylocain; this was done under fluoroscopy to ensure the correct nerve roots were blocked. Next they carefully marked (aka: mapped) the areas on the patients skin that were numbed by the Xylocain nerve blocks. The results were tabulated and are shown below; however, the bottom line is this: "The L4 nerve root innervates (connects, gives-life-to) the medial side (inside) of the lower leg in 88% of the patients tested. The L5 nerve root innervates the side of the first digit (big toe) on the dorsum (top) of the foot in 82% of the patients. The S1 nerve root innervates the side of the fifth digit of the foot in 83% of the individuals." (2)

Although the majority of patients seem to share the same 'nerve root dermatomal distributions' (wiring), this investigation has clearly demonstrated that the neural anatomy of the lumbar spine does have some degree of variation, i.e., some 20% of the patients did NOT have the typical 'nerve root dermatomal distributions'. For example, in some patients, a L5 nerve root block would result in numbness of the S1 dermatome and not the anticipated L5 dermatome (2).

I've based my recommended Dermatome Maps (as has Volvo Award Winner Dr. Nikolai Bogduk) on Nitta's work simply because today, this is the most accurate information we have on nerve root sensory distribution.

DERMATOME MAPS:

S1 RADICULAR PAIN:

If the L5 disc herniates into the 'lateral recess' (which is where it usually does) and compresses / irritates the descending S1 nerve root, the patient may suffer an S1 radicular pain (aka: S1 root-pain, or S1 Sciatica). Fig.# 4 shows the regions in the lower limb where the patient will most likely suffer the symptoms of S1 sciatica (2). As you can see, the majority of patients (75%) suffer the burning, stinging, and numbing pain of sciatica in the lateral foot, posterolateral leg, thigh, and butt, as well as, the bottom, outer 1/2 of the foot. These pains are the result of damage and irritation to the 'sensory portion' (portion of the nerve root which connects to skin) of the nerve root.

If the 'motor portion' (portion of the nerve root which connects to muscle) of the S1 nerve root is damaged or irritated by the disc herniation, the patient my suffer weakness and/or atrophy in the Gastrocnemius muscle (the calf), the peroneal muscles (foot evertors), and/or the muscles which flex or curl the 'big toe'. The Achilles' Reflex and Plantar Reflex may also be diminished or absent. If severe, the patient will be unable to do 'calf raises' with the effected foot. Calf raising is the 'gold standard' muscle test for S1.

L5 RADICULAR PAIN:

If the L4 disc herniates into the 'lateral recess' (which is where it usually does) and compresses / irritates the descending L5 nerve root, the patient may suffer an L5 radicular pain (aka: L5 root-pain, or L5 Sciatica). Fig. # 5 shows the regions in the lower limb where the patient will most likely suffer the symptoms of L5 sciatica (2). As you can see, the majority of patients (75%) suffer the burning, stinging, and numbing pain of sciatica in the top and inner surface (dorsum) of the foot, the outer-front of the leg, and the bottom of the big toe. These pains are the result of damage and irritation to the 'sensory portion' (portion of the nerve root which connects to skin) of the nerve root.

If the 'motor portion' (portion of the nerve root which connects to muscle) of the L5 nerve root is damaged or irritated by the disc herniation, the patient my suffer weakness in the Extensor Hallusis Longus muscle (muscle that lifts the big toe - classic finding) or the muscles that dorsi-flex the foot (lift the foot up) upward. If severe, the patient will be unable to 'walk on their heals' with their toes and ball-of-the-foot off the ground. There is no reliable reflex test for this nerve root.

L4 RADICULAR PAIN:

If the L3 disc herniates into the 'lateral recess' (which is where it usually does) and compresses / irritates the descending L4 nerve root, the patient may suffer an L4 radicular pain (aka: L4 root-pain, or L4 Sciatica). Fig. # 6 shows the regions in the lower limb where the patient will most likely suffer the symptoms of L4 sciatica (2). As you can see, the majority of patients (75%) suffer the burning, stinging, and numbing pain of sciatica in the top and inner surface (dorsum) of the foot, the outer-front of the leg, and the bottom of the big toe. These pains are the result of damage and irritation to the 'sensory portion' (portion of the nerve root which connects to skin) of the nerve root.

If the 'motor portion' (portion of the nerve root which connects to muscle) of the L4 nerve root is damaged or irritated by the disc herniation, the patient my suffer weakness in the quadriceps muscle (muscle that extend the knee). If severe, the patient will be unable to perform a squat or get out of a chair because. If the problem is severe, the patient will often have a diminished or absent Patellar Reflex (aka: knee jerk).

 

REFERENCES:

1) Kortelainen P, et al. “Symptoms and signs of sciatic and their relation to the location of the lumbar disc herniation.” Spine – 1985; 10:88-92

2) Nitta H, et al. "Study on dermatomes by means of selective lumbar spinal nerve root block." Spine 1993;18:1782-6

31) Uihlein A, et al. "neurologic changes, surgical treatment, and post operation evaluation. Symposium: Low back and sciatic pain." J Bone Joint Surg 50A:1, 1968

32) Bolk L. "Die Segmentaldifferenzigrung des menschlichen Rumpfes und seiner Extremitaten." morphol Jahrb 1898 - 1899; 25:465-543; 26:91-211; 27:630-711; 28:105-46