A frequent microvascular complication of diabetes is diabetic neuropathy.  The most common type is distal symmetric neuropathy or polyneuropathy (DPN).  DPN results in significant disability and morbidity (1, 10).  Complications of DPN include severe pain, loss of ambulation from foot deformities and increased risk of foot ulceration, infection, and ensuing amputation (10, 11). Sadly, life-time risk of foot amputation is 15% in patients with diabetic polyneuropathy (11) The televised soda campaign in NY shows a gruesome albeit advanced image of an unchecked diabetic foot.  While the most common pattern of diabetic neuropathy is DPN, other patterns of neuropathy exist.  These include autonomic neuropathy, small fiber neuropathy, polyradiculopathy, diabetic amyotrophy, and focal mononeuropathies (1,2).   Diabetic polyneuropathy (DPN) involves the distal lower extremities with sensory involvement greater than motor and autonomic involvement (1,12,14,16).  Generally involvement of motor nerves occurs later in the development of the disease.  Early motor involvement increases the diagnostic severity of DPN (12, 16)  Other pathophysiologic processes associated with diabetic neuropathies include a predisposition to compression and repetitive injury (1).  Superimposed mononeuropathies or entrapment neuropathies, like carpal tunnel syndrome, commonly occur in patients with DPN (1,14)

Incidence of polyneuropathy have been reported in 10–50% of patients with diabetes (11). At the time of diagnosis, neuropathy is already present in 10% of diabetic patients.  Many studies show that often early signs of neuropathy predate an official diagnosis of diabetes.  In the Rochester Diabetic Neuropathy Study, 45% of DM type II patients had quantitative changes, clinical and electrophysiologic studies, although only 13% had neuropathic symptoms (1).   In another report, prevalence of neuropathy early in diabetes increased to 50% but only with quantitative sensory testing and nerve conduction studies (2) This occurs in part because a majority of diabetics can have objective sensation loss without accompanying symptoms (2). Nerve conduction can play an important role in group of people because electrophysiologic signs of neuropathy are detectable despite clinical symptoms (4, 6).   Kimura noted that when both abnormal nerve conduction attributes and/or delayed F waves were involved, evidence of neuropathy occurred in 60% of patients without clinical signs and in 96% with clinical signs (3).  Lee et al, noted that children with IDDM frequently have nerve conduction abnormalities without clinical neuropathy at initial diagnosis (8).  All these studies support the common notion that early detectable of evidence of nerve injury can be found regardless of the patient’s complaints.  Changes in nerve function represent a normal and often unavoidable consequence of diabetes.  However, not all patients necessarily develop ensuing complications.  The more important question attempts to make sense of the findings to determine the type of intervention. 

The sural nerve provides a good diagnostic starting point (2, 5, 13, 17).  Amplitude and velocity changes early in the course of the disease help note glycemic control and the development of neurological impairment.  Including the medial plantar sensory nerve increased the sensitivity up to 70% in the detection of neuropathy and allowed earlier diagnosis, especially when routine nerve conduction studies is normal (5).  Attributes of the peroneal motor nerve also predicts the progression of diabetic neuropathy and the development of neurological impairment especially when considered with increased triglyercides early in the course of disease (2, 17).  In general, conduction slowing and respective neuropathy correlates with disease duration (4).   Alone this is not an indicator of neurological progression rather an expression of glucose metabolism and microvascular changes.  When the velocity of the fastest conducting fibers is maintained, the prognosis is favorable.  Neurological impairment is less likely in this instance.  The integrity of axons–the smaller components or fibers that make up a nerve—plays a larger role in determining impairment.  This tends to occur more with time and/or disease severity.  More axonal loss equates to increased neurological impairment.  If axonal regeneration does keep pace with degeneration, denervation can be seen and heard during EMG (1).  In extreme cases, chronic denervation can lead to atrophy (12, 16).   Also small detectable changes in nerve conduction are a sensitive indicator of progressive nerve dysfunction and response to treatment even when lab testing is normal (2,4,13).  In this respect, electrodiagnostic evaluation can help gauge the severity of neuropathy and provide a prognosis as to neurological impairment. 

Of course, every test has its limitations.  Electrophysiologic findings do not always translate to clinical impairment.  For this reason, a diagnostic test should never be used alone.  Clinically, contrasting loss of sharp touch and temperature with subjective increased pain is common (1,2, 7,9,12).  Decreased vibration and position sense occurs frequently but is less sensitive (2, 7,9,12).  Decreased ankle reflexes are also common as well as the electrodiagnostic equivalent—H reflexes.  Distal small muscle weakness and atrophy may occur in chronic or uncontrolled cases. (1, 2, 7, 9).  While clinical findings help diagnose DPN, nerve conduction studies provide a more powerful tool that can helps identify subclinical cases for early intervention (7, 9).

Nerve conduction studies are also insensitive to the function of small C fibers and autonomic B fibers.  These are often impaired early with poor glycemic control despite normal NCV.  However, there are other electrodiagnostic tests that can evaluate these nerves. 

Combining laboratory studies with information gained from the history, examination, and electrodiagnostic testing, usually identifies 74 to 82% of cases (1).  For example, nerve conduction studies abnormalities in sub-clinical DPN are highly correlated to HbA1c levels over 7% (6).  In a previously undiagnosed population with documented neuropathy, an impaired glucose tolerance test was more sensitive that fasting blood sugar in diagnosing glycemic control more so than HbA1c elevations (2).   HbA1c seems to be more linked to small fiber neuropathy and autonomic dysfunction especially in type one diabetics (1, 2).  Hypertension and elevated triglycerides are also predictive factors in the development of neuropathy with diabetes (2).  In type 1 DM, long term glycemic control, diabetes duration and HbA1C, are associated with low nerve conduction velocity and amplitude response (17). 

 People rarely have one issue at a time.  An electrodiagnostic evaluation helps differentiate the diagnosis and note co-morbidities.  In the last month, I have seen several diabetic patients with varying degrees of neuropathy and neurological impairment.  These cases caught my attention.  An early case of diabetic amytrophy with positive EMG findings, thigh weakness and a history of mild spinal stenosis.  A case of apparently well controlled diabetes, hypothyroidism and leg cramping, where thyroidism proved more of an issue than diabetes.  A third case of moderate to severe peripheral vascular changes, distal muscle atrophy, and denervation due to uncontrolled diabetes. This case was complicated by history of disc herniated with radiculopathy.   Lastly, a diabetic with constant cramping in the feet who was thought to have plantar fascitis and showed electrodiagnostic evidence of selective involvement of sensory-motor fibers in the peroneal nerve bilaterally.  He was recommended for further lab testing to rule out hereditary sensori-motor neuropathies.  Following are three more interesting case studies:

1. Tracy JA, Engelstad JK, Dyck PJ. Microvasculitis in diabetic lumbosacral radiculoplexus neuropathy. J Clin Neuromuscul Dis. 2009 Sep;11(1):44-8. FREE
2. Tavee J, Zhou L. Small fiber neuropathy: A burning problem. Cleve Clin J Med. 2009 May;76(5):297-305. FREE
3. Cho KT, Kim NH. Diabetic amyotrophy coexisting with lumbar disk herniation and stenosis: a case report. Surg Neurol. 2009 Apr;71(4):496-9.  ABSTRACT

From a chiropractic standpoint, consider diabetes a contributing factor when treating your patients.  When patients show objective clinical changes despite subjective complaints explore the issue further especially if they tell you that they are pre-diabetic or you suspect they might be diabetic. Perform a brief distal motor-sensory-reflex exam on diabetic and pre-diabetic patients a couple times a year to keep tabs on early objective changes.  If patients have had an NCV/EMG, look beyond confirmed radiculopathy or entrapment neuropathies.  If neuropathic signs are evident on NCV/EMG without clinical symptoms of neuropathy and these patients have no history of diabetes, request lab work or refer to the primary care physician and/or endocrinologist for evaluation of glucose tolerance, elevated H1bAc, and tryglyceride levels.  If they have a history of diabetes, send a copy of the test to the primary care physician and/or endocrinologist as this can provide useful information on glycemic control and ensuing neuropathies.  Remember, diabetic neuropathy and more importantly neurological impairment can be prevented when treated early.  Treatment of diabetic neuropathy focuses on maintaining normal blood sugar levels.  This helps to prevent progression of the neuropathy and neurological impairment (1-9). Glycemic control proved to be a greater risk factor over 5 years in the progression of subclinical neuropathy (8).  With intensive treatment to optimize glycemic control, there is a 64% risk reduction in the development of neuropathy after 5 years. Even in treatment-naive type 1 diabetic patients with confirmed clinical neuropathy, optimal glycemic control can reduce symptoms of peripheral neuropathy (1,2).  

REFERENCES

1.  Vavra, Michael W., Rubin, Devon I. The Peripheral Neuropathy Evaluation

in an Office-Based Neurology Setting.  Semin Neurol 2011. 31:102–114

2.  Habib A, Brannagan TH.  Therapeutic Strategies for Diabetic Neuropathy.  Curr Neurol Neurosci Rep 10: 92-100

3.  Kimura J.  Motor Neuron Excitiability and Late Responses.  19^th Annual Course & Symposium.  Basic and Advanced Techniques in Electrodiagnosis.  Columbia University. June 2010

4.  Gilchrist JM, Sachs G.  Electrodiagnostic Studies in the Management and Prognosis of Neuromuscular Disorders.  Muscle Nerve 29: 165-190

5.  Uluc K, Isak B, Borucu D, Temucin CM, Cetinkaya Y, Koytak PK, Tanridag T, Us O. Medial plantar and dorsal sural nerve conduction studies increase the sensitivity in the detection of neuropathy in diabetic patients. Clin Neurophysiol. 2008 Apr;119(4):880-5

6.  El-Salem K, Ammari F, Khader Y, Dhaimat O. Elevated glycosylated hemoglobin is associated with subclinical neuropathy in neurologically asymptomatic diabetic patients: a prospective study. J Clin Neurophysiol. 2009 Feb;26(1):50-3

7.  Asad A, Hameed MA, Khan UA, Butt MU, Ahmed N, Nadeem A. Comparison of nerve conduction studies with diabetic neuropathy symptom score and diabetic neuropathy examination score in type-2 diabetics for detection of sensorimotor polyneuropathy. J Pak Med Assoc. 2009 Sep;59(9):594-8.

8.  Lee SS, Han HS, Kim H. A 5-yr follow-up nerve conduction study for the detection of subclinical diabetic neuropathy in children with newly diagnosed insulin-dependent diabetes mellitus. Pediatr Diabetes. 2010 Dec;11(8):521-8

9.  Feldman EL, Stevens MJ, Thomas PK, Brown MB, Canal N, Greene DA.  A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis and staging of diabetic neuropathy. Diabetes Care.1994 Nov;17(11):1281-9.

10.  Kosinski, MA, Lipsky BA.  Current Medical Management of Diabetic Foot Infections

Expert Rev Anti Infect Ther. 2010;8(11):1293-1305

11.  Booya F, Bandarian F, Larijani B, Pajouhi M, Nooraei M, Lotfi J.  Potential risk factors for diabetic neuropathy: a case control study.  BMC Neurology 2005, 5:24

12.  Said G, Baudoin D, Toyooka K. Sensory loss, pains, motor deficit and axonal regeneration in length-dependent diabetic polyneuropathy. J Neurol. 2008 Nov;255(11):1693-702

13.  Brown MJ, et al.  Natural Progression of Diabetic Peripheral Neuropathy in the Zenaresta Study Population.  Diabetes Care 27:1153–1159, 2004

14.  Johnson, E. W. (1993), Sixteenth annual AAEM Edward H. Lambert lecture. Electrodiagnostic aspects of diabetic neuropathies: Entrapments. Muscle & Nerve, 16: 127–134.

16.  Andersen, H., Stålberg, E., Gjerstad, M. D. and Jakobsen, J. (1998), Association of muscle strength and electrophysiological measures of reinnervation in diabetic neuropathy. Muscle & Nerve, 21: 1647–1654.

17.  Charles M, Soedamah-Muthu SS, Tesfaye S, Fuller JH, Arezzo JC, Chaturvedi N, Witte DR; EURODIAB Prospective Complications Study Investigators. Low peripheral nerve conduction velocities and amplitudes are strongly related to diabetic microvascular complications in type 1 diabetes: the EURODIAB Prospective Complications Study. Diabetes Care. 2010 Dec;33(12):2648-53.

In retrospect, these patients presented with certain commonalities:  involvement in cervical acceleration-deceleration injury; positive yellow flags; significant cervical muscle instability; and a subsequent but notable change in pain after injections.  Specifically, these patients complained of burning pain after injection.  Based on Murphy’s Diagnosis Based Clinical Decision Rule[7] [8] and Chou’s recent study on predicting disability[9], these patients had underlying factors that would perpetuate their pain and predispose them to developing chronic pain.  I suspect the injections sensitized nociceptors in muscle that had been irritated from de-conditioning after injury.  As a result, these patients progressed from nociceptive pain to neuropathic pain and continued into hyperalgesia.  According to Smith, in the presence of biopsychosocial factors the neurological phenomenon of sensitization augments aversion to pain, makes pain pre-eminent, and can lead to a regressive trauma experience¹⁰.  Aversion is a psychological term that encompasses such behaviors as catastrophizing, fear avoidance, and anxiety/depression related to pain[10].  This train of thought provided a useful staring point but lacked a clear direction.

Delving deeper into the body of evidence, one paper showed promise.  A paper written this year addressed muscle pain amenable to injection (MPAI)[11].   Marcus proposes that not all muscles will respond to injection and the likelihood of a positive response can be attained by a selection algorithm.  This is consistent with Staals suggestion that specific subgroups of patients may respond to a specific type of injection therapy ¹.  Marcus offered a few important suggestions in this paper.  First, that the injectate or chemical/material injected is of little importance.  Second, that multiple strategic injections through the MTJ and muscle belly induce micro trauma to promote a new phase of healing.  This approach is reminiscent of remodeling strategies found in ART and Graston.  Marcus determined MPAI by selecting target muscles that elicit pain along the entire length of the muscle from origin to insertion including the musculotendinous junction (MTJ.)  This makes sense because the MTJ contains the highest density of mechano- and nociceptors in the muscle.  Preceding and following injections, Marcus emphasizes a strict yet simple muscular rehabilitation program.  This also makes sense.  Murphy tells us that instability is an important perpetuating factor of spinal pain.  When stabilizing muscles cannot support the spine, global/primary movers take on the role of stabilizing the spine.  I have yet to meet a person that enjoys doing someone else’s job! Apparently, muscles respond similarly.  They rebel after misuse, signal the brain and result in neck/head pain.  Unless, underlying stability is addressed, muscle and neck pain will continue. 

However, these patients presented further challenges.   Stability exercises subjectively increased pain initially even though objectively it helped control pain when performed consistently.   As a result, patients did not want to perform exercises because they did not think it would help and they preferred passive care.  These are common fear avoidance and passive coping behaviors.  Lis advises that patients with yellow flags require more attention and increased counseling from the treating doctor to prevent disability.  In the care of patients presenting with biopsychosocial factors, Lis recommends reassurance from the doctor that improvement will follow adherence to treatment guidelines, an explanation that hurt does not mean harm, and a focus on stress management techniques to counteract the mind-body connection[12]. 

Evidence-based care recommends selecting the best treatment targeted at the primary pain generators, addressing underlying perpetuating factors to thwart chronicity and counseling to squelch a disability mindset early ^{8,9 10, 12,} [13] . These patients may have benefitted from an evaluation of MPAI early in their care.   On one hand, if their muscle pain had not been amenable to injection, this strategy would have prevented the regression of symptoms and provided reassurance that an aggressive rehabilitative program would have helped.  On the other hand, had they been suitable candidates for injection, symptom relief would have provided reassurance of improvement and motivation to capitalize on rehabilitative strategies.  As we learn, grow, and share clinical best practices our patients will benefit. 

[1] Staal JB, de Bie RA, de Vet HC, Hildebrandt J, Nelemans P.  Injection therapy for subacute and chronic low back pain: an updated Cochrane review. Spine (Phila Pa 1976). 2009 Jan 1;34(1):49-59.

[2] Chou R, Atlas SJ, Stanos SP, Rosenquist RW.  Nonsurgical interventional therapies for low back pain: a review of the evidence for an American Pain Society clinical practice guideline. Spine (Phila Pa 1976). 2009 May 1;34(10):1078-93. Review.

[3] Kim JE, Kang JH, Choi JC, Lee JS, Kang SY. Isolated posterior femoral

cutaneous neuropathy following intragluteal injection. Muscle Nerve. 2009 Nov;40(5):864-6.

[4] Cheng J, Abdi S. COMPLICATIONS OF JOINT, TENDON, AND MUSCLE INJECTIONS. Tech

Reg Anesth Pain Manag. 2007 Jul;11(3):141-147. PubMed PMID: 18591992

[5] Unglaub F, Guehring T, Fuchs PC, Perez-Bouza A, Groger A, Pallua N.

Necrotizing fasciitis following therapeutic injection in a shoulder joint.  Orthopade. 2005 Mar;34(3):250-2. German. PubMed PMID: 15703892.

[6] Benyamin RM, Vallejo R, Kramer J, Rafeyan R. Corticosteroid induced psychosis

in the pain management setting. Pain Physician. 2008 Nov-Dec;11(6):917-20.

[7] Murphy DR, Hurwitz EL.  A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain.  BMC Musculoskeletal Disorders 2007, 8:75

[8] Murphy DR, Hurwitz EL, Nelson CF.  A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature.  Chiropractic & Osteopathy 2008, 16:7

[9] Chou R, Shekelle P.  Will this patient develop persistent disabling low back pain?

JAMA. 2010 Apr 7;303(13):1295-302.

[10] Smith, M.  Pyschosocial Management of the Patient with Chronic Low Back Pain.  NYU Hospital for Joint Disease.  Comprehensive Spine Course. NYU Langone Medical Center.  Nov 12, 2010.

[11] Marcus N, Gracely E, Keefe K.  A Comprehensive Protocol to Diagnose and Treat Pain of Muscular Origin May Successfully and Reliably Decrease or Eliminate Pain in a Chronic Pain Population.  Pain Medicine 2010; 11: 25–34pme_752

[12] Lis, A.  Translating Research into a Clinical Spine Practice. NYU Hospital for Joint Disease.  Comprehensive Spine Course. NYU Langone Medical Center.   Nov 11, 2010.

[13] Chou R. Evidence-based medicine and the challenge of low back pain: where are we now?Pain Pract. 2005 Sep;5(3):153-78.

Anyhow, this month Spine Journal has several interesting abstracts.  Of note, there is prize winning article on the linear association of Schmorls nodes and the severity of DDD (1).   Unfortunately, “the correlation between radiologic changes and chronic low back pain is weak, [even though] these investigations are often used by clinicians as an explanation of the underlying cause for pain (2).”  This is nothing new as research has been showing that what your spine looks like is not always relevant to your case.  I have posted on this before and you can find articles on my discussions board in FB.  However, this author suggests that as doctors we often encourage unhelpful beliefs.  The words we use to describe images–X-ray, MRI–tend to develop negative ideas in the patients mind.  This can lead to a disability mindset and is terribly dis-empowering for people.  However, the author suggests that the “explanation of radiological findings to patients presents an opportunity to challenge unhelpful beliefs” so clinicians can encourage patients to pursue  active treatment strategies (2).

This option empowers people to become participants in their care.  It de-victimizes them and de-catastrophizes the scenario so people can regain control of their life.  Long story short, do not be discouraged by the words used to describe pictures of your back.  They are not necessarily a reflection of the the person or the pain they feel.  Most back pain episodes can be successfully treated conservatively.  Patients can learn strategies to help with future less painful occurrences.  Learn more.  Check out Myths about Back Pain on Spine-Health.com.

1.  Mok F, et al.  ISSLS Prize Winner: Prevalence, Determinants, and Association of Schmorl Nodes of the Lumbar Spine With Disc Degeneration: A Population-Based Study of 2449 Individuals.  Spine: 1 October 2010 – Volume 35 – Issue 21 – pp 1944-1952

2.  Sloan TJ, Walsh DA.  Explanatory and Diagnostic Labels and Perceived Prognosis in Chronic Low Back Pain.  Spine:1 October 2010 – Volume 35 – Issue 21 – pp E1120-E1125

Several companies in NJ, including some the Best Places to Work in NJ,  have implemented wellness initiatives either independently or in partnership with outside organizations.  In fact, a literature review prepared for the World Health Organization demonstrates that several national and international companies are following this route¹³.   Quad/Graphics, a self funded company, successfully implemented an on-site wellness program in 1991 that reduced health care costs twenty percent while increasing employee satisfaction and overall value¹.  More important, early intervention saved this company 2 million dollars in estimated costs.  American Standard created a three year strategy to create awareness, change behaviors, and drive participation in their wellness initiative.  More importantly, they customized their approach to meet the needs of their employees.  This program created an estimated savings of 1.6 million in their first year².

According to Prudential, the economy’s negative impact on business culture has led to a reduction/freeze of benefit spending and staff size as well as a reduction in perceived value by plan sponsors and employees³. Cost containment remains a top priority and will likely continue to play a significant role in the coming years³.  Health prevention via education, lifestyle coaching, pre-habbing, and wellness initiatives represent the most cost effective strategy for addressing benefit costs^3,4,5,6,20. 

It is common knowledge that health affects every aspects of life:  employment, relationships, mental state, and leisure.  The best way to protect assets, income, and lifestyle is to stay healthy^3,4,11,13,20.  Prudential’s benefit study reflects this basic concept.  They show a growing employee interest in health/wellness^3,4.  In fact, healthcare ranks in the top three employee concerns and is the second reason, next to salary, for job consideration^3,6.  Moreover, employees view early retirement as less likely.  This makes health an important factor in employment since people may be working past the traditional retirement age³. 

Good news:  prevention saves money.  For low back pain, conservative care increases the value of insurance by providing better outcomes with significantly lower cost effectiveness ratios versus physician care ⁵.  Ironically, this study notes that even with a five-fold cost increase, conservative would still be a more cost effective option in the long run ⁵.  The value of prevention holds true whether addressing pre-hypertension, obesity, metabolic syndrome or back pain.  It also holds true for screening procedures that catch potentially serious conditions early on ^{5,6,9,11,15,17}.  Work place wellness initiatives that incorporate education, lifestyle coaching, and/or link business goals to benefit value increase savings as well as the perception of value for the employee^{1,2,6,7,11,20}.

Consider the case.  According to the National Health Interview, only 10% of persons in all ages considered themselves in fair or poor health ^8,9.  Not terrible.  However, only 32% of adults over 18 engage in regular leisure-time physical activity^8,9.  Nothing new right.   We already know most people should exercise more.   Moving on.  21% of people over 18 currently smoke ¹⁸.   In adults over twenty, 34% are obese¹⁸ and 32% have hypertension¹⁹.  These three factors combined make the ten percent number noted earlier less likely.  The health statistics also note that 37.3 million persons were limited in their usual activities due to one or more chronic health conditions⁷.  About 12.3 million adults aged 18–69 years were unable to work due to health problems, and 6.9 million were limited in the kind or amount of work they could do because of their health⁷.  Perhaps people are less healthy than they think.  Actually, 34% of people over twenty show evidence of metabolic syndrome, a combination of health indicators associated with the leading causes of death in US:  heart disease, cancer, stroke, diabetes, respiratory disease, hypertension¹².  This syndrome is preventable.  In fact, 90% Americans have preventable risk factors and the average employee has at least 2 preventable risk factors^8,10. 

Not convinced.  Consider the following points.  Spending on spine related problems reach 85 billion dollars annually ⁵. From 1998 to 2005 the Workplace Safety & Insurance Board (WSIB) reported a 38% increase in the proportion of injured workers who remain on benefits at least 12 months, with low back pain the most common cause of persistent disability claims ²⁰.  Cigarette smokers are 2 – 4 times more likely to develop coronary heart disease than non-smokers and cigarette smoking approximately doubles a person’s risk for stroke¹⁴.  Cigarette smoking is also linked to almost every major cancer.  About 90% of all deaths from Chronic Obstructive Pulmonary Disease (COPD) are attributable to cigarette smoking¹⁷.  Poor diet and physical inactivity cause 310,000 to 580,000 deaths per year and are major contributors to disabilities that result from diabetes, osteoporosis, obesity, and stroke¹⁵. A study conducted by the Diabetes Prevention Program (DPP) showed that weight loss through moderate diet changes and physical activity can delay and prevent type 2 diabetes¹⁶.  Heart disease, cancer, stroke, diabetes, respiratory diseases, and hypertension are a few of diseases that stem from chronic unchecked, lifestyle induced inflammation—metabolic syndrome–that could be diverted with simple lifestyle changes¹².  Does the picture look different?

In 2007, business goals to reduce health cost superseded interest in improving employee health⁴.  However, employee health drives cost and is a major factor influencing productivity ^6,11,13,20.  Research consistently demonstrates that prevention and early, specific intervention outweigh treatment in terms of cost and effectiveness.  Healthy employees are cheaper to insure ^6,11,13.  They have less unplanned absences due to sickness or injury^6,11.  Healthy employees are less likely to utilize Short Term Disability, Long Term Disability, or Worker’s Compensation^3,4,6,13,20.  Prudential’s study notes that companies doing more to integrate services achieve more success and demonstrate better results in each survey category.  They specifically note a significant increase in employee health and employee responsibility for health³.  Those companies highly involved in running integrating wellness models showed the highest ROI (Return on Investment) and increases in productivity³.  From a numerical standpoint, wellness initiatives and disease management programs lead results in terms of integrative approaches^3,4.  Interestingly, annual medical expenses for persons with BMI of 30 to 34 cost $1,400 more (25% greater costs) then those of ideal weight persons.  Raise the BMI and cost goes up.  Persons with BMI > 35 cost $ 2,267 more then ideal weight persons.  While ideal weight is arguable the numbers are not.  This increase represents 44% greater costs, but hope exists.  High risk employees who convert to low risk, lower costs by as much as 30% within 2-5 years¹¹.

In the wake of economic turmoil, health is returning to the forefront.  Chiropractors have been long-time advocates of preventative care.  We are hands down the best health practitioners for back pain, neck pain, and headaches²¹.  In light of a looming shortage of family doctors due to over specialization, evidenced-based Chiropractors can help fill the gap.  As healthcare providers, we rule out serious illness and refer people to appropriate specialists²².  We can add value because we have musculoskeletal training that most family doctors do not have²².  More importantly, we focus on lifestyle modifications– smoking cessation, smarter nutrition, stress reduction, and physical activity–to reduce health costs by improving health. 

References:

1.  Zastrow R, Quadracci L.  Engaging Quad/Graphics Employees in the Improvement of their Health and Healthcare.  J Ambulatory Care Manage. May 2006.  29:3.
2. Thompson M, Checkley J. Employer Driven Consumerism:  Integrating Health into the Business Model.  Benefits Quarterly.  Second Quarter 2006.
3. Study of Employee Benefits: 2009 and Beyond.  The Prudential Insurance Company of America.
4. The Market for Integrated Health Care and Disability Management. The Prudential Insurance Company of America. January 2007.
5. Choundry N, Milstein A.  Do Chiropractic Physician services for treatment of low back and neck pain improve the value of health benefits plans:  An evidenced-based assessment of incremental impact on population health and total health spending.  Mercer.  October 2009.
6. Woolf S, Husten C, Lewin L, Marks J, Fielding J, Sanchez E. The economic argument for disease prevention: distinguishing between value and savings.  Partnership for Prevention, 2009.
7. Adams PF, Heyman KM, Vickerie JL. Summary health statistics for the U.S. population: National Health Interview Survey, 2008. National Center for Health Statistics. Vital Health Stat 10(243). 2009.
8. Summary Health Statistics for the U.S. Population: National Health Interview Survey, 2008 Appendix III table V
9. Early release of selected estimates based on data from the National Health Interview Survey, data tables for figures 7.1, 8.1, 9.1
10. National Health Interview Survey, 2001;Am J Prev Med 2004;27(2S)
11. Parkinson M.  Obesity Worksite Interventions: Perspective From the Health Care Front.  Presentation. Lumenos, Inc.  2004
12. Ervin RB. Prevalence of Metabolic Syndrome Among Adults 20 Years of Age and Over, by Sex, Age, Race and Ethnicity, and Body Mass Index: United States, 2003–2006.  National Health Statistics Reports. 13.  May 5, 2009
13. Engbers L, Sattelmair J.  Monitoring and Evaluation of Worksite Health Promotion Programs – Current state of knowledge and implications for practice. World Health Organization 2008
14. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. Retrieved at http://www.cdc.gov/tobacco/basic_information/health_effects/heart_disease/index.htm
15. Promoting Healthy Eating and Physical Activity for a Healthier Nation. Division of Nutrition and Physical Activity. National Center for Chronic Disease Prevention and Health Promotion. CDC.
16. National Diabetes Information Clearinghouse. Retrieved at http://diabetes.niddk.nih.gov/dm/pubs/riskfortype2/index.htm
17. U.S. Department of Health and Human Services. Reducing the Health Consequences of Smoking—25 Years of Progress: A Report of the Surgeon General.
18. Health, United States, 2009, table 72
19. Health, United States, 2009, table 68
20. Amendolia C, et al.  Designing a workplace return-to-work program for occupational low back pain:  an intervention mapping approach.  BMC Musculoskeletal Disorders 2009, 10:65
21. Bronfort G, Haas M, Evans R, Leiniger B, Triano J.  Effectiveness of manual Therapies: The UK Evidence report.  Chiropractic & Osteopathy 2010, 18:3
22. http://www.drgrisanti.com/mddc.htm

Doctors of Chiropractic spend more time studying muscles and joints than the typical family doctor.  In fact, they spend more time treating common muscle and joint injuries than the average doctor or orthopedist because many injuries respond well to conservative care.  However, an orthopedist is your best choice in cases of severe injury with grade 3 ligamentous tears or compromised joint integrity.  Nevertheless, a good orthopedic exam will help determine the difference.

Soft tissue therapy targeting muscles, tendons, and certain ligaments can alleviate painful movement, repetitive strains, and promote rapid healing. One study noted that half of the patients seen by 330 pain specialist, orthopedists, and rheumatologists were treated for myofascial pain.  Most of these patients were prescribed medications and/or physical therapy.  The doctors rated the effectiveness as moderate noting that treatment options were insufficient (1). But research shows that manual therapy for soft tissue pain and sport-related injury provides favorable outcomes (12). 

Joint manipulation complements soft tissue treatment.  Manipulation improves involuntary and voluntary coordination between muscles and joints that affect balance, coordination and performance. A recent review of scientific literature noted that hands-on care provides favorable results for many common sport related injury (12).  The outcome is faster return to sport and consistent performance with less injury.

Shoulder injuries, for example, occur in 71% of athletes. However, shoulder injuries are often missed in general practice. This delays early treatment (2). The most frequent shoulder conditions involve the rotator cuff muscles, the shoulder joint—glenohumeral or acromioclavicular–and pain referral from the neck (2, 4).  In fact, many athletes experience multiple shoulder problems simultaneously. This issue stems from delayed treatment.  Consider that almost half of patients complain of persistent pain twelve months after initial consultation (2).  Early and specific intervention is critical.  The key factor lies in using a combination of shoulder tests to locate injury around the joint or inside the joint (2, 3).  Injuries within the joint may require surgical intervention but can be rehabilitated depending on the severity of the injury.  In either case, early and accurate treatment improves results.  Initial treatment should include supervised rehabilitation including restoration of the scapular and arm movement.  Correcting faulty movement patterns reduces pain and improves functional motion while reducing joint dysfunction associated with compensation (3, 5).  Strengthening exercises do not decrease hypermobility–excessive joint movement–but they improve overall control and function.  When conservative treatment fails, surgical options may be indicated (3, 4).  However, research shows that conservatively treated patients experience less immobilization time (casting/slinging) and faster return to sport activities than patients undergoing surgery.  Not to mention, the added advantage of avoiding complications associated with surgery (4).

Common elbow and wrist injuries can also be treated with manual therapy, manipulation and mobilization.  For example, tennis elbow and golfer’s elbow respond well to various types of myofascial release and exercises targeting the muscle origins at the elbow.  This approach provides better long term results than steroid injections (12).  Wrist injuries can be rehabilitated using finger and wrist extension exercises as these tend to be weaker compared to the opposing muscle group.  Moreover, joint manipulation/mobilization may add value to soft tissue treatment by improving communication between joints and muscles (12).

Many people do not realize that muscles stabilizing the back contract before limb movement.  Gross motor movement is an orchestrated effect of smaller actions that depend on stable structures and appropriate muscle response.  The spine acts as in important anchor for arm and leg motion.  Remember that low back pain is prevalent, affecting 80% of the general population.  Some sports like, football, tennis, and golf create excessive torque and stress to discs and joints.  The spine was designed to withstand vertical loads, not twisting forces.  In general, compressive (vertical) loads to unstable structures results in injury.  This insult can accumulate with repetitive motion or result in significant pain when these motions occur abruptly.  Also, motion that combines twisting with bending (either forward or backward), i.e. “corkscrewing”, sets the stage for potential injury.  After repetitive movements, the body takes time to regain its original position.  In the spine, this is known as creep.  Creep reduces the resistance to load and interferes with the distribution of forces.  In addition, torque generated from twisting the upper body instead of the hips creates rotational stress on discs and joints (6).  Combined, these factors contribute to mechanical stress that promotes injury and affects involuntary muscle balance, coordination and response.

Moving down the body, knee injuries account for 40% of sport injury.  Interestingly, over 70% of ACL injuries occur in non-contact situations that involve landing, decelerating and changing direction.  Biomechanics research has also shown that unplanned cutting is identified as a risk factor of non-contact ACL injury.  The rotation mechanism during pivoting movement also contributes to added stress on the knee.  Some athletes rotate the upper body and thigh on pivoting.  However, when the fore foot is sticking on the ground, the tibia is rotated internally–the opposite direction (7).  This is example of torsional (twisting) stress on the knee and in particular the ACL.   Repetitive stress causes micro injury in the ligament that can eventually lead to larger tears.  While there is no direct treatment for torn or tethered ACL, functional stability determines return to sport.  Conservative care might encompass decreased quadriceps inhibition (9), neuromuscular re-education, tibial manipulation, muscle activation as well as addressing the ripple effects on the spine caused by the lower kinetic chain (12).  Functional stability can then be gauged in terms of jumping, cutting, quick stopping and pivoting (7). 

Shin splints—medial tibial stress syndrome—represent another example of sport-related injury that effects performance.  While you cannot manipulate shins you can mobilize the fibula and bones in the ankle that contribute to forces transferred to the shins. Cold laser treats inflammation (12).  Soft tissue treatment addresses micro trauma to irritated muscles and ligaments.  Lastly, balance exercises and eccentric strengthening may also help address dynamic stability of the ankle:  another factor associated with shin splints (8, 9). 

Sports related injuries affect more than joints and muscle.  School sport concussions are gaining attention.  Many states, including NY/NJ, are considering return to play legislation for concussion and head collision due to a high number of recorded injuries.  The CDC estimates 300,000 head injuries every year.  An internet search will yield significantly higher figures.  The National High School Sports-Related Injury Surveillance Study reported 68,000 concussions in the 2008 football season.  Those figures do not include unreported cases that increase the risk of repeat or more severe injury.  One potential solution to this is “baselining” athletes.   Baselining refers to a health screen before play or injury occurs.  By pre-screening athletes, the doctor and coach can get a better sense for changes in neurological and mental status to determine safer return to play (11).  Of importance, sports play a big role in inner-city life for the same reasons it predisposes this population to injury.  Social-economic status often impacts health directly via access and affordability, as well as, indirectly in terms of emotional/physical stressors and nutritional choices.  Ironically, sports provide a much needed distraction (11, 12).  Thankfully, Wells Fargo joined forces with the Sport Concussions Institute (SCI) to introduce the first insurance policy specifically for scholastic sports concussions.  “This removes the financial barrier for players to receive the specialty care they deserve, especially those from underprivileged communities who play high-velocity sports. The cost is very low – you can get $10,000 worth of coverage for about $4 per player per year, and it covers them across the entire season (11).” For more information search Play It Safe Concussion Care Program on the web.

In closing, consider these tips in preparation for spring sports. 

• Don’t wait to address “sprains” or “strains.” These generally do not require intensive treatment.  Early intervention keeps the athlete performing well and avoids chronic injury.
• Adding core and functional exercises to a fitness regime will help increase dynamic stability of the spine that acts as the anchor for all arm/leg movement.
• Neuromuscular training helps the body respond to unplanned motion.
• Understanding body mechanics helps avoid injuries.
• Joint manipulation improves communication between joint motion and muscle response.
• “Baselining” athletes provides a good tool for quicker/safer return to play.
• Anti-inflammatory nutrition plays a critical role in rapid healing.

References: 

1. Fleckenstein J, Zaps D, Ruger LJ, Lehmeyer L, Freiberg F, Lang PM, Irnich D.  Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: Results of a cross-sectional, nationwide survey.  BMC Musculoskeletal Disorders 2010, 11:32.
2. Fowler EM, Horsley IG, Rolf CG. Clinical and arthroscopic findings in recreationally active patients.  Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2010, 2:2.
3. Kim S.  Multidirectional instability of the shoulder – current concept.  Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2009, 1:12.
4. Gumina S, Carbone S, Arceri V, Rita A, Vestri AR, Postacchini F.  The relationship between chronic type III acromioclavicular joint dislocation and cervical spine pain. BMC Musculoskeletal Disorders 2009, 10:157
5. Roy JS, Moffet H, McFayden B, Lirette R. Impact of movement training on upper limb motor strategies in persons with shoulder impingement syndrome.  Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2009, 1:8 .
6. Chow J, Park SA, Tilman M.  Lower trunk kinematics and muscle activity during different types of tennis serves.  Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2009, 1:24.
7. Lam M, Fong DT, Yung PS, Ho EP, Chan W, Chan K.  Knee stability assessment on anterior cruciate ligament injury: clinical and biomechanical approaches.  Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2009, 1:20. 
8. Raissi GD, Safar Cherati AD, Mansoori KD, Razi MD.  The relationship between lower extremity alignment and Medial Tibial Stress Syndrome among non-professional athletes.  Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2009, 1:11.
9. Alfredson H, Pietela T, Johnsson P, Lorentzon R.  Heavy Load Eccentric Calf muscle training for the treatment of Chronic Achilles tendonosis.  The American Jouranl of Sports Medicine.  May 1998, 26 (3).
10. Suter E, McMorland G, Herzog W, Bray R.  Conservative lower back treatment reduces inhibition in knee-extensor muscles: a randomized controlled trial.  J Manipulative Physiol Ther. 2000 Feb;23(2):76-80.
11. SAMSON, K.  School Sport Concussions Draw National Attention as More States Draft Return-to-Play Laws.  Neurology Today: 4 March 2010 – Volume 10 – Issue 5 – pp 1,12–13.
12. Parker R, Jelsma J.  The prevalence and functional impact of musculoskeletal conditions amongst clients of a primary health care facility in an under-resourced area of Cape Town. BMC Musculoskeletal Disorders 2010, 11:2.
13. Bronfort G, Haas M, Evans R, Leiniger B, Triano J.  Effectiveness of manual Therapies: The UK Evidence report.  Chiropractic & Osteopathy 2010, 18:3
14. Murphy DR, Hurwitz EL.  A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain.  BMC Musculoskeletal Disorders 2007, 8:75
15. Murphy DR, Hurwitz EL, Nelson CF.  A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature.  Chiropractic & Osteopathy 2008, 16:7
16. Seaman D.  Clinical Nutrition for Pain, Inflammation, and Tissue Healing.  NutrAnalysis, Inc., 1998

Fortunately, recommendations offered by the American College of Radiology (ACR) and literature reviews help shed light on this important question. 

Pain by itself is insufficient to substantiate the need for an MRI.  Even when taken to verify specific and reproducible complaints MRI provides meager results.  Two reasons explain this phenomenon.  First, while MRI detects many significant lesions, it often misses soft tissue injuries even after trauma.  A negative MRI doesn’t mean you are in the clear.  Numerous reports have documented low rates of undiagnosed spine injuries that required later repair or worsening symptoms (1).  Second, MRI detects many clinically insignificant lesions.  Although MRI detect many lesions, it is not clear how many of those lesions identified on MRI are clinically significant (1).  That means MRI often generates many false positive examinations.  Specifically, imaging may not match the patient’s history or complaint and sometimes produces no complaints at all.  In addition, to date, there are no established criteria for distinguishing significant from inconsequential abnormalities seen on MRI.  Overall, these results imply that soft-tissue injuries are quite common after significant trauma and many of these lesions do not lead to mechanical instability despite the presence of pain (1).

For the above reasons, the ACR has deemed MRI of the neck least appropriate when  there is low risk of injury; suspected but unconfirmed injury following acute trauma; or on follow up after previous CT scan showed no evidence of instability even when a neck collar may have been used prophylactically.  For mid and low back injuries, the ACR gave MRI an appropriateness rating of 5 out of 9 which leaves the decision in the hands of your doctor (1). In the face of this decision, many will turn to current literature for guidance. 

So when is MRI recommended? The ACR guidelines suggest MRI for people with possible spinal cord injury and clinical concern for cord compression, in those suspected of having ligamentous instability or suspected arterial injury.  As a note, cord injury is not the same as nerve root injury.  The former is more severe and can have lasting consequences if not handled appropriately.  On the other hand, nerve root injury while very common and often painful and disrupting it is not generally life threatening.  Moreover, nerve root injury can usually be treated conservatively with good results. 

As mentioned earlier, the ACR guideline on MRI for low back pain is somewhat ambiguous.  Fortunately, sufficient research exists to help guide the need for advanced imaging.  As a general rule, scientific evidence advises against imaging patients with nonspecific low back pain within the first six weeks unless severe or progressive neurologic symptoms are present, or serious underlying conditions is suspected (2-6). Nevertheless, about two-thirds of MRI occur within the first month of pain onset, despite clinical guidelines that recommend waiting at least four weeks to see if patients recover on their own or with conservative care as many do.  In fact, imaging (X-ray, MRI, or CT scan) for low-back pain without indications of serious underlying conditions does not improve patient results in the short term (less than three months) or long term (six months to one year.) Therefore, the literature recommends that doctors refrain from routine, immediate imaging in patients with acute or sub-acute low back pain unless they suspect a more serious underlying condition (5).  Moreover, surgery is not warranted within the first three months to a year of non-specific low back pain because there is no evidence that the patient will experience better results (2, 4).  In fact, the initial benefits of surgery are lost in the long term and compare to non-surgical outcomes. Worse still some studies report surgery for non-specific low back pain within the first year despite evidence to the contrary (2).  Let me be clear that in cases of cord compression with severe or rapid neurologic deficit or in cases of severe instability surgery is often the best option for patients.  However, this is not the case with non-specific low back pain.   The results are similar for neck pain.  No evidence supports specific MRI findings with associated neck pain, cervicogenic headache, or whiplash exposure.  In fact, in the absence of serious injury, a good clinical examination is better at ruling out structural lesions causing neurological symptoms (3).  Nevertheless, people worry when they experience new symptoms or their pain continues for a long time because they feel something is wrong.  This worry reinforces their desire for advanced imaging as they believe it will provide help address their symptoms.  This idea can ring true for many things but not so much with back pain.

Scientific research suggests the following recommendations for treating low back pain (6).  First, doctors should conduct a focused history and physical exam to categorize patients with low back pain into 1 of 3 broad categories: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause. The history should include assessment of psychosocial risk factors, which predict risk for chronic disabling back pain.   Another researcher takes this recommendation a step further by categorizing patients into one of the four most common sources of back pain which helps select a more precise strategy for addressing the patient’s pain (7, 8).  Second, doctors should not routinely obtain imaging or other diagnostic tests in patients with low back pain.  Third, doctors should request diagnostic imaging and testing for patients with low back pain when severe or progressive neurologic deficits are present or when serious underlying conditions are suspected on the basis of history and physical examination.   Fourth, doctors should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis preferably with magnetic resonance imaging only when they are potential candidates for surgery or invasive procedures, i.e., epidural steroid injections.  Fifth, doctors should (a) provide patients with evidence-based information on their expected course of low back pain, (b) advise patients to remain active, and (c) provide information about effective self-care options like stretching, strengthening, ergonomics, etc.  Sixth, doctors should consider the use of medications with proven benefits in conjunction with back care information and self-care when necessary. For many patients, acetaminophen or over the counter non-steroidal anti-inflammatory drugs (NSAID) such as ibuprofen provide an effective first-line of relief.  Doctors that combine this approach with conservative treatment or alternative options will likely provide the best care and results for patients suffering from back pain.

Back pain is huge health issue in the United States.  That is why it has been studied extensively.  Scientific evidence provides better information every day.  For now, a diagnosis based protocol follows current recommendations and directs treatment towards addressing primary pain generators and other factors that perpetuate back pain (7, 8). Doctors of Chiropractic are qualified non-surgical spine specialists poised to direct back care.  After handling the initial emergency, many chiropractors can continue to advise patients how to avoid future episodes of debilitating pain in addition to providing guidance on several lifestyle factors to create a true model of wellness.  In this way, we can help patients achieve a better quality of life.

References:

1. Spine Trauma Imaging recommendation ACR. National guideline clearinghouse. 11 2008
2. Samson K.  Low Back Pain MRIs, Surgery Rates Higher in Areas with More Units. Neurology Today.  Nov 09. 9 (22)
3. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15;33(4 Suppl):S101-22.
4. Chou R, et al. Surgery for low back pain: a review of the evidence for an American Pain Society Clinical Practice Guideline. Spine (Phila Pa 1976). 2009 May 1;34(10):1094-109.
5. Chou R, et al.  Imaging strategies for low-back pain: systematic review and meta-analysis. Lancet. 2009 Feb 7;373(9662):463-72
6. Chou R, et al.  Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007 Oct 2;147(7):478-91.
7. Murphy DR, Hurwitz EL.  A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain.  BMC Musculoskeletal Disorders 2007, 8:75
8. Murphy DR, Hurwitz EL, Nelson CF.  A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature.  Chiropractic & Osteopathy 2008, 16:7

 Central pain hypersensitivity describes a physiological process whereby uninterrupted painful stimulus increases the nervous system’s sensitivity incoming signals.  Nerve receptors that respond to various sorts of tissue damage are called nociceptors.  There are three types of nociceptors with varying degrees of function.  When injured tissue repetitively stimulates nociceptors, their firing threshold lowers, they fire more frequently and with less stimulus.   The continued stimulation of nociceptors magnifies and the brain receives more signals.  As a result, pain feels stronger and is more easily elicited even though the initial insult may not have worsened. 

 Two manifestations of central pain hypersensitivity include hyperalgesia or allodynia.  Hyperalgesia denotes exaggerated pain to normally painful sensations.  Allodynia, on the other hand, represents painful sensation caused by non-painful stimulus, e.g., clothing touching the skin, light touch.

 Early intervention and prevention remains the best safeguard against central pain hypersensitivity.  Rapid pain relief is key.  Diagnosing and treating the source of pain often provides the fastest relief.  Diagnosing is an important part of this strategy because it provides a road map to effective and timely results. 

 In addition to diagnosis based treatment, behavior also plays a role in precipitating symptoms because pain is an emotion.  The magnification of pain creates worry that something is wrong and emotional stress increases.  As a result, the elevated stress contributes to an increased pain response.  However, “hurt” and “harm” do not always mean the same thing.  Most mechanical injuries are painful.  However, they usually are not life threatening.  The presence of pain does not necessarily mean the injury is getting worse.  This concept helps prevent anxiety over pain.  For this reason, patients should also actively seek strategies to manage their pain.  This approach empowers the patient and can have a powerful psychological effect in controlling pain.  However, when patients are mismanaged and self-help strategies fail, the continued search for relief produces anxiety and frustration or, worse still, depression.   Overall, active coping offers a better option than the alternative.  Ignoring the problem neither addresses the pain nor the source.  Passive coping can have a serious effect on the patients psyche and quality of life (1, 2).

 According to research, acupuncture is not the best approach for low back pain or neck pain (3).  However, several studies support the pain reducing effects of acupuncture (4-13).  Acupuncture reduces pain via two different mechanisms.  One decreases the stimulation of nerve signals that lead to pain.  The other reduces the expression of inflammatory chemicals that stimulate nerve endings that cause pain.  Both of these mechanisms likely co-exist. 

 On one hand, scientists believe that acupuncture physically interrupts nerve signals from pain fibers, and among nearby pressure receptors, that attenuate signaling to the spinal cord (4, 10).  This mechanism of action may temporarily interfere with low level stimulation of pressure sensitive receptors in the skin, called merckel cells, and decrease pain signals reaching the spine.  This study supports others that suggest merckel cells participate in pain modulation.  Another author suggests a review of possible explanations for the pain reducing effects of acupuncture.   For example, Acupuncture is thought to release opiate-based chemicals which exert a pain reducing effect much like morphine (7).  The release of dynorphin, a natural opioid, may accelerate tolerance to chronic inflammatory pain (9).  Acupuncture also seems to release serotonin in the central nervous system (7, 10).  This chemical is well known to stimulate centers in the brain that ultimately block pain pathways starting in the spinal cord.  This action interrupts pain signals before reaching the brain.  Third, acupuncture may inhibit a group of nerves in the sympathetic nervous system that regulate inflammation and pain (7, 11).  The sympathetic response–typically known as the flight or fright response–kicks in when we experience stress.  Polymodal nociceptors—one of the three types of “pain” receptors mentioned earlier– monitor the body’s ability to maintain a stable internal environment.  So polymodal nociceptors monitor internal stress and influence inflammatory signaling through the sympathetic nervous system.  Less inflammation reduces pain (11).  Of note, the mechanical and neurological mechanism of pain reduction in acupuncture mirrors the therapeutic effect of chiropractic manipulation. 

 In addition to the mechanical and neurological blocking of pain, acupuncture appears to affect pain induced by chemical inflammation.  A surplus of literature link inflammation and pain.  Inflammation is not bad because it is the first phase of normal healing.   The problem arises when healing remains or lingers in this stage much longer than it should.  When this happens, chronic pain, disability, or central pain hypersensitivity may develop. 

 Acupuncture blocks chemical receptors that promote inflammation.  For example, one study demonstrated how acupuncture counteracted increased pain associated with nerve growth factor and Substance P at the site of injury and in the spine (6). Another study notes that acupuncture releases anandamide from inflamed tissues.  Anandamide is a chemical that binds to and activates cannabinoid receptors that block pain transmission and results in pain reduction (5).  The hypersensitivity of tissue surrounding an injury may be partially due to disruption of the endocannabinoid system which normally acts to inhibit nerve transmission.  This system may be linked to merckel cells (mentioned earlier) and pain modulation.  Interestingly, these chemicals resemble the active ingredient in cannabis which may partially explain its pain reducing effect in chronic pain sufferers.  Acupuncture also seems to suppress Cox-2 in the spinal cord (8).  Cox inhibitors are commonly used for reducing pain associated with inflammation.  Many common over the counter drugs such as Advil, Motrin, or Aspirin are cox inhibitors.  Acupuncture also attenuates the affects of pro-inflammatory chemicals that have a long association with pain:  interleukin and nitric oxide (12, 13).   Scientists continue to study the relationship between acupuncture and inflammation as an alternative to pain reduction.

 Based on the literature, acupuncture can influence pain mechanically, neurologically, and chemically.  Patient selection and diagnosis-based treatment determines the effectiveness of any treatment.  Acupuncture may provide a helpful strategy for reducing pain in a particular sub-group of patients.  People with consistently high levels of pain that find no relief from traditional or alternative therapies may benefit from acupuncture.  More importantly, high pain levels limit the effectiveness of manual treatment. Acupuncture may provide gradual exposure that helps de-sensitize pain receptors and increases patient tolerance to painful activities and/or manual treatment that targets the source of pain.  From a non-surgical standpoint, acupuncture provides an alternative approach for lowering pain to a tolerable level that allows treatment in the same way that epidural steroid injections or joint blocks decrease pain to allow aggressive manual treatment in patients minimally responsive to a trial of conservative care.

 As a side note, if you dislike needles, dietary changes can control pain related to inflammation.  My professor once said people eat pain.  Many people view diet as a luxury instead of a necessity.  This mindset leads to habitually poor dietary choices that create a greater pain response through a low level state of chronic inflammation.  All good books on nutrition touch on this painful fact.  For this reason, a diet high in fruits and vegetables with moderate levels of carbohydrates and meats; miniscule quantities of refined grains, sugars, and other processed food products ultimately decrease pain and promote rapid healing (14).  Lifestyle changes have the greatest impact on health.  Unfortunately, they are the hardest changes to make.

 References:

1. Murphy DR, Hurwitz EL.  A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain.  BMC Musculoskeletal Disorders 2007, 8:75
2. Murphy DR, Hurwitz EL, Nelson CF.  A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature.  Chiropractic & Osteopathy 2008, 16:7
3. Lewis K, Abdi S.  Acupuncture for lower back pain: a review. Clin J Pain. Jan;26(1):60-9.
4. Silberstein M.  The cutaneous intrinsic visceral afferent nervous system: A new model for acupuncture analgesia.  J Theor Biol. 2009 Sep 16.
5. Chen L, et al.  Endogenous anandamide and cannabinoid receptor-2 contribute to electroacupuncture analgesia in rats.  J Pain. 2009 Jul;10(7):732-9. Epub 2009 May 5
6. Aloe L, Manni L.  Low-frequency electro-acupuncture reduces the nociceptive response and the pain mediator enhancement induced by nerve growth factor.   Neurosci Lett. 2009 Jan 16;449(3):173-7. Epub 2008 Nov 7
7. Lin JG, Chen WL.  Acupuncture analgesia: a review of its mechanisms of actions.  Am J Chin Med. 2008;36(4):635-45.
8. Lau WK, et al.  Electroacupuncture inhibits cyclooxygenase-2 up-regulation in rat spinal cord after spinal nerve ligation.  Neuroscience. 2008 Aug 13;155(2):463-8. Epub 2008 Jun 14.
9. Huang C, et al.  Electroacupuncture effects in a rat model of complete Freund’s adjuvant-induced inflammatory pain: antinociceptive effects enhanced and tolerance development accelerated.  Neurochem Res. 2008 Oct;33(10):2107-11. Epub 2008 May 7.
10. Li A, et al.  Electroacupuncture suppresses hyperalgesia and spinal Fos expression by activating the descending inhibitory system.  Brain Res. 2007 Dec;1186:171-9. Epub 2007 Oct 22. 
11. Kim HW, etal.  Low-frequency electroacupuncture suppresses carrageenan-induced paw inflammation in mice via sympathetic post-ganglionic neurons, while high-frequency EA suppression is mediated by the sympathoadrenal medullary axis.  Brain Res Bull. 2008 Mar 28;75(5):698-705. Epub 2007 Dec 26.
12. Garrido-Suárez BB et al. Pre-emptive anti-hyperalgesic effect of electroacupuncture in carrageenan-induced inflammation: role of nitric oxide.Brain Res Bull. 2009 Aug 14;79(6):339-44. Epub 2009 May 3
13. Song MJ, et al.  Additive anti-hyperalgesia of electroacupuncture and intrathecal antisense oligodeoxynucleotide to interleukin-1 receptor type I on carrageenan-induced inflammatory pain in rats.Brain Res Bull. 2009 Mar 30;78(6):335-41. Epub 2008 Nov 18
14. Seaman D.  Clinical Nutrition for Pain, Inflammation, and Tissue Healing.  NutrAnalysis, Inc., 1998 

Spinal Decompression alleviates pressure within the disc by creating space around the compressed nerve root.  Decompression also allows nutrients to flow in/out of the disc space which normally occurs more slowly.  The disc receives blood supply through the outer portion of the disc and through the outer surfaces of the vertebra on which the disc rests.  Since blood supply is often limited healing occurs more slowly. 

In the non-surgical setting, decompression is achieved by axial traction.  Axial traction can be explained as a stretch caused forces pulling in opposite directions.  Several methods exist to accomplish this end. 

Static traction stretches the patient to tolerance and holds that position for a several minutes.  Dynamic traction, also called intermittent traction, is similar to the above but cycles between periods of increased stretch and release over a period of several minutes which creates a cycled pressure change within the disc.  Many of the spinal decompressions machines utilized by Chiropractors employ dynamic or intermittent traction.  Insurance usually does not cover this procedure so patients typically pay for services out of pocket.

Flexion-Distraction or distraction manipulation is another type of spinal decompression usually performed manually by the treating doctor.  Flexion Distraction would fall under the category of dynamic traction.  However, it is more variable as the stretch and timing of treatment can be quickly adjusted by the treating doctor so the patient achieves the most benefit and least amount of discomfort.  Moreover, this treatment option is performed within a shorter period of time compared to intermittent traction.  The patient is slightly flexed or angled after being stretched which creates further space in the posterior structures of the spine and the intervertebral foramen (where nerves exit the spine.)

Flexion-Distraction offers more interaction between the doctor and patient.  It is just as effective as mechanical decompression which makes it a good first option.  Moreover, flexion-distraction will usually be covered as manipulation or manual therapy depending on your insurance plan.  Every patient is unique and so results may vary.  If this treatment does not work for you can always try the other static or dynamic traction machines.  

As a whole, spinal decompression is helpful when patients are properly selected.  Spinal care should always be diagnosis-based and tissue specific to achieve the best results.  The doctor should identify the herniated disc as the source of your pain.  Remember, not all herniations cause pain.  However, when your pain radiates into the arm or leg a herniation is more likely.   The doctor may perform orthopedic tests that stretch the nerve (neural tension tests) in various positions to determine the extent of the lesion.  When other methods of conservative care fail to provide results intermittent decompression machines may provide relief. 

In the event a person experiences intractable pain after exhausting conservative approaches, invasive procedures such epidural steroid injections or nerve blocks and surgical decompression provide other options.  In this case, a pain specialist provides strategies for managing pain.  This avenue is a viable option for those patients that refuse surgery and do not mind periodic injections to quell and control pain.  Surgery has several concerns associated with it but has proven effective in those cases where conservative treatment fails to provide relief.  An orthopedic surgeon or neurosurgeon would be best suited to discuss this option. 

As a final note, diet heavily influences the perception of pain.  The American diet tends to be highly inflammatory and will increase the pain response in most people by inducing pro-inflammatory chemicals in the body (prostaglandin, thromboxane, prostacyclin, leukotriene, tumor necrosis factor, interleukin, vascular endothelial growth factor, nerve growth factor, and several more).  Unfortunately, diet is one of the most difficult habits to change and advice often falls on deaf ears.  Those people brave enough to honestly question and change lifestyle can find several informational websites and books to help them along. 

 References:

Gay R,  et al. Stress in Lumbar Intervertebral Discs during Distraction:  A Cadaveric Study.  Spine J. 2008 ; 8(6): 982–990.

Kruse R, et al.  Chiropractic treatment of a pregnant patient with lumbar Radiculopathy.  Journal of Chiropractic Medicine (2007) 6, 153–158

Gudavalli MR, Cambron JA, McGregor M, et al. A randomized clinical trial and subgroup analysis to compare flexion-distraction with active exercises for chronic low back pain. Eur Spine J 2006;15(7):1070-82

Bergmann TF, Jongeward BV. Manipulative therapy in lower back pain with leg pain and neurological deficit. J Manipulative Physiol Ther 1998;21(4):288-94.

Seaman DR. Clinical nutrition for pain, inflammation and tissue healing. Hendersonville (NC): NutrAnalysis, Inc.; 1998

The transverse abdominal and pelvic floor muscles are crucial for stabilizng the lumbopelvic spine during activity.  In fact, the transverse abdominal muscle is the first muscle to contract on all activity even before moving your limbs.  This stabilizes your spine. 

Proper abdominal breathing exercises the diaphragm.  Many people use the muscles in their shoulders and neck for breathing.  Improper breathing can creat undue stress in these areas. 

In conclusion, if your back pain arises from muscular instability, Yoga may help address these underlying contributors to your pain and offer you relief.