Watch and learn as I go over some very mind boggling studies that were so tedious that I had to drink 8 cups of coffee in order to pay attention to professor Slossberg reviewing them. Fortunately for you, I’ll make it a little more fun and more importantly, extremely worth your while. Most doctors find this material incredibly difficult and thus their poor results, and this is why I’m trying to write this in a user-friendly manner because you really can’t count on your family doctor to give you the right advice with regard to spinal pain. If you find you are not getting it, just keep going because I’m going to say it in a simpler way by the end of the paragraph or that specific topic. If you somehow are able to manage to continue reading past this you will find that it keeps getting more interesting throughout and there are some unexpected great gems with regard to living longer not just preventing back pain.
It’s important to keep in mind that almost all the research being reviewed with intense brevity was performed by Ph.D. scientists and M.D.’s. Almost no chiropractic studies will be evaluated and at no time during this review were actual chiropractors used or hurt in the making of this epic book report. This means that the scientists who did perform cervical adjustments did so with a device that a monkey could be trained to use in less than 5 minutes. Absolutely no skill in the art of chiropractic was factored into their research. And yet, even with the least powerful form of chiropractic, you’ll see they got some amazing results.
I don’t want to footnote this, but I better now because it will be easier for me later when someone accuses me of just pulling this stuff out of my butt. However, my idea of footnoting is a little different than research scientists. I’m just going to number the studies 1-x.
Low back pain is now considered a recurrent intermittent syndrome that erupts periodically over the course of a lifetime. That means you are not getting over it with that one visit from the discount chiropractor. Until 10 years ago, low back pain was considered purely biomechanical and it involved finding the anatomic damage then choosing from a host of practitioners; a way to fix it. That seems to be failing miserably and the new paradigm is that it is a multifactorial biopsychosocial pain syndrome. They now feel that back pain is composed of 10 factors and only 3 are things that back doctor’s address; the remaining 7 are psychosocial factors.
So in spite of what insurance companies tell you, you are not going to get over a bad back by just keeping a stiff upper lip. It is not a short term situation. The assumption underlying current guidelines that spontaneous recovery occurs in a large majority of patients is not justified. I’m harping on this now, but you will not see why until later.
MRI’s and all other high tech tests cannot find the cause of most acute low back pain. It is now considered to be poor control of low back muscles that allows tissues such as ligaments and tendons to become damaged. 4. But how do you control muscles that you have no control over? The deep core muscles that stabilize our spines are not volitional type muscles like you have in your fingers. They are anti-gravity muscles controlled largely by your subconscious. One thing that may appear evident at this point is that we want more function, not pain relief. 1. 35.
Only a small percentage of patients seek care for low back pain since most episodes are rarely disabling. Most new episodes recover in a few weeks. Of the patients who do seek care, 62% will continue to have pain a year later. 16% who were off work will still be off work 6 months later. One predictor of who will be out of work forever is if the patient hired an attorney. 80% of people who sought primary medical care for their back ache would still have it over a year later. About 6% of people with low back pain, who seek treatment, wind up going to a chiropractor, which these days, means they have to pay for it. That can be interpreted as; chiropractors get the worst of the worst cases. 2.
It doesn’t fare any better for neck pain. 50% to 85% of people with neck pain will have it 1 to 5 years later. So this means that short term care does not change the natural long term history of spinal pain, which leads me to this old joke. How many chiropractors does it take to screw in a light bulb? Just one, but it takes him 120 tries. You’ll shortly see why you should be glad that joke is based on anecdotal and now scientific truth. 3.
There is little direct evidence that most back pain stems from a discrete injury or repetitive trauma. Back pain seldom results from a fall, direct impact or extraordinary physical demands. So now that we know what doesn’t cause it, what does? Repeat after me, disturbance of motor control. That means when you are sitting for a long time, you lose the normal lordotic curve( the arch produced by bending backwards) in your spine and the muscles that support your spine are shut off. Your ligaments now begin to get overstretched and the nerve signals coming from those tissues and the joints in general are no longer helping to control the muscles that stabilize the spine.
That is one reason why police officers have such a high incidence of disabling back pain. They are sitting for hours. That means the muscles are not being used. Then they have to quickly jump out of the car and chase a criminal. The muscles have not been working and the spine is allowed to shear over its discs. The amount of neuronal control needed to stabilize the spinal segments is tremendous and most of us lose it early on in life. Sitting is considered not only a chief component and predictor of low back pain, it is now also been shown to be a main factor in metabolic syndrome to be discussed down below, somewhere.
For more than 50 years spine clinicians were obsessed in their search for a diagnosis, the cause of pathology, the generator of spinal pain. It is now considered to be a waste of time and money. Researchers spent millions of dollars and can’t do it and that is good news for you because many chiropractors don’t even want to diagnose. They just like to adjust the spine and research has proven it to be the most effective stand alone treatment. Combined with exercise it is by far the most effective tool known to medical science.
What about ergonomics you ask? It turns out, it doesn’t do all that much. The majority of herniated discs are not associated with anything traumatic, cumulative, or inheritable. 5, 6. A study of twins did discover that lumbar disc degeneration is heritable except for disc height. 7.
I found that interesting because most of us are not twins, but will get a backache. O.K. the point is, a decreased disc height was often blamed for the back pain, but this means you can’t blame it on your parents. With regard to the workplace, the exercise model is now surpassing the ergonomic model. 36. Exercise is coming up somewhere down below.
How does chiropractic treatment hold up compared to surgery? 60% of sciatic patients who had failed other medical management benefited from spinal manipulation to the same degree as if they underwent surgical intervention that did benefit them. 8. I think it is safe to say after reading that study that you would have been better off sticking with the chiropractor. But it is not just me who feels this way; the most successful hospital in the United States, the University of Pittsburgh medical Center (U. P. M. C.) Health plan, an HMO affiliated with the University school of medicine, requires that patients with low back pain undergo chiropractic care before surgery can be considered. 37.
What is a good predictor of back pain that doesn’t cost anything? Balance. Poor balance indicates poor motor control of the core stabilizing muscles. These muscles are innervated via subconscious pathways. You can’t turn one vertebra one way and the one below it the other way. These stabilizing muscles are under control of your subconscious antigravity system also known as your cerebellum and vestibular system. (Balance system) If you can’t come up with a good motor program to shunt your muscles, you are going to injure your spine. The motor programs are made in the part of your brain just in front of the sensory and motor strips. So what does this really mean? If the spinal joints are not functioning properly, large parts of your brain are not going to work right and that usually results in you not working right. If only there were medical doctors who could fix this problem? Sadly, there are not, but thankfully, we do have chiropractors who do fix these problems.
Radioisotope studies and PET scans have shown the brain being greatly stimulated with spinal joint manipulation. Remember, you can’t consciously control the multifidi (these muscles are located on the spinal bones below all other muscles) and are main stabilizing muscles. The control of these muscles is happening in subconscious centers of the central nervous system so collateral stimulation from other parts of our bodies and brain wind up producing the best results. What am I talking about? Have you seen wobble boards at the gym? That is going to fire up nerve pathways to the cerebellum, send nerve signals down the vestibular spinal tracts and get DNA to replicate and create more muscle mass in that muscle you have no direct control over. Weak muscles hurt and more muscle mass is a good indicator of less back pain.
What is going wrong when you sit? The core spinal stabilizing muscles are shut off. The ligaments are now being overused and their nerves are fatiguing and sending incorrect signals. This actually causes a disruption of molecular bonds that hold muscles, tendons and ligaments together. The first muscle activated from prolonged sitting to standing is the multifidus, that subconscious core stabilizing muscle. It doesn’t do a whole lot of stabilizing when it has been turned off for a long time. Said a slightly different way from different research, continuous brisk passive cyclic loading produces drastic reductions in the muscular stabilizing reflex and exposes the spine to destabilizing injury. The reduction in the protective ligamento-muscular reflex is a direct manifestation of mechano-receptor desensitization caused by laxity in viscoelastic tissues of the spine. A 10 minute rest period produced only 20-25% restoration of EMG activity in the multifidus muscle. It turns out that sitting for awhile takes a day to completely recover from. The spinal joints remain unstable for up to 24 hours. 9. It just occurred to me that according to this research, it’s amazing that we can even stand up at all. I guess we have to keep in mind that research scientists really don’t do well in the real world, but I find this stuff interesting none the less.
The mechanoreceptors mentioned above are special anti-gravity and positional nerve receptors that chiropractors utilize to get the amazing results that all these medical research articles are interested in. These are the largest and fastest nerves in the human nervous system and as mentioned above when stimulated at a spinal level, has global effects because of their large influence on the brain, so chiropractic is not just good for the corner of back ache that we have been painted into and more and more studies reveal that spinal manipulation is, get this, good for your health as well.
The avoidance of expensive tests for diagnosing back pain was mentioned above, but why do chiropractors get so much information out of just a simple check for range of motion? The two major components responsible for spine stability become less functional: increased laxity of the viscoelastic tissues ( ligaments, discs, facet capsule, dorso-lumbar fascia, etc.) and core stabilizing muscles. When we sit flexed forward/slumped micro-damage occurs to the collagen fibers of the elements listed above in parenthesis. The sensory nerves in the ligaments and these other tissues result in reflexive changes of posterior lumbar musculature and these muscles become less responsive allowing spinal injuries because they are not doing their job, which is to hold the spinal bones very tight together so they do not shear over the discs.
This kind of damage in ligaments is referred to as creep and it is repaired by the body’s inflammatory responses. However, the chemicals involved in inflammatory responses further lowers the threshold of the sensory nerves in the ligaments, which means they fire easier and unintentionally and that can create spasm, which most definitely hurts. More inflammation, more spasm, and less range of motion the things chiropractors are checking for, especially at low tech spinal screenings that you most probably been hocked at while walking in the mall. A chiropractic adjustment specifically activates the multifidus muscles and keeps them active for over a week. 10
So far I have 10 footnotes and please keep in mind that I have already read 20 studies from different colleges all over the world saying basically the same thing, so you can thank me later for sparing you from the pain that I’m going through right now.
All my patients blame an external event on their back pain, such as turning to look at something. It turns out that it is not external loads but dynamic conditions that create havoc. It really is internally caused. 65% of the mass of our body is above the waist. Well, that is a lot like an external load. When we are sitting, the natural curve in the lumbar spine is decreased and that causes ligament laxity and stretch receptors to become desensitized. That means you are more likely to get a back ache when those muscles have to suddenly be used. MRI’s of people’s spines that are sedentary show very atrophied Multifidi muscles. These muscles are key to not getting a back ache and if seen by an unqualified doctor, that can lead to surgery.
Surgery by the way destroys these muscles to some degree and hence, the second surgery because the first one failed. I guess there is a little good news for those of you that are not convinced. Surgeons are now being taught to injure the multifidus less during spine surgery. 34.
I’ll sparingly discuss some brain anatomy. The neurons at the most anterior of the post central gyrus respond to proprioception. That means the nerves in your muscles and joints that tell you where you are in space and time help maintain balance, tell you to shake a hand firmly and pick up an egg gently are eventually winding up on the conscious portion of your brain. Not all that information goes to just your subconscious (cerebellum). The sensory nerves from our joints and muscles go to a sensory strip and in front of it is a motor strip and in front of that is a part of your brain that figures out movements. From learning a song on a piano to figuring out how you are going to stand on one leg at the top of a ladder replacing a light bulb, there is a part of our brain dedicated to figuring that stuff out. It makes sense anatomically that these areas would be next to each other. But sense of position of body parts is comprised not only of proprioceptors, the special nerves in joints and muscles, but also from the visual information in the occipital cortex (the back of your brain), and the vestibular system-(balance system) ( in the inner ear). 11
You may know all that as the drunk test. The cop pulls you over and checks your balance. Close your eyes and even a non impaired person can fall over. However, we should not fall over. If you are losing your balance because of a lack of thalamic stimulation from your visual system, then your vestibular system (balance system) is not working right. That is the system that fires those deep multifidus back stabilizing muscles and those muscles are going to be weak. I just saved you a thousand bucks on that MRI. I just ask my patients to close their eyes and observe which way they fall over. While it is fun for me to watch you fall, it is definitely not fun for you to be stuck in a very narrow loud tube for one hour. (The MRI is very claustrophobic and as we already learned, doesn’t tell us a whole bunch) How much do the multifidi muscles contribute to lumbar spine stability? 66% and these muscles are the only muscles to stabilize the Sacro- Iliac joints below the lumbar spine. More on the S.I. Joints a major area of pain somewhere down below. 12.
Speaking about vicious cycles? There is a part of your brain (corticospinal tracts) involved with firing the muscles sitting to the side of the very centered multifidi muscles (involuntary muscles). These voluntary muscles that are further out from the mid-line are called the erector spinae. The part of the brain that allows you to turn your back the way you want to shows decreased activity in chronic low back pain patients. Is it low back pain or lack of brain function causing the pain? Apparently it looks like both. 13. The good news is your brain can reorganize following injury and new motor skills can be learned. This is the first time that it was observed with high tech brain scans that motor training can reverse networks in the motor cortex. Obviously we all knew this because we’ve seen stroke victims learn to walk again, but science will not accept just plain old observation and common sense and therefore this expensive study becomes ground breaking. So doing core exercise routines can fix your brain and even though we don’t normally associate brain activity with preventing low back pain, we now should see it that way. 14.
However, big however hear, it is very possible to poorly train your brain so that you can compensate for painful movements in the short term. However, in the long run, poor reorganization can cause some muscles to experience overload while causing others to have reduced activity with consequent atrophy. These changes may contribute to the development of chronic symptoms and partially explain histological (cellular) changes in muscles that ache after trauma. Pain actually changes the molecular structure of our cells. In biology we always say structure determines function and chiropractors know that poor structure is going to cause global dysfunction.15.
While I said above that MRI’s can’t find the cause of acute low back pain, it sure can detect the cause of chronic low back pain. That would be atrophied and fatty infiltration of multifidi muscles. The good news here is that conditioning these muscles thru progressive resistance exercises reverses these muscular dysfunctions and structural abnormalities. 16. Little bad news though for you people thinking about exercising in pain to save a buck. Pain can hinder the cortical neuroplastic changes associated with novel motor-skill acquisition. So two studies to say that pain equals gain of……. more pain and dysfunction.
Pain related changes in the excitability of the primary motor cortex may contribute to protective motor control strategies such as reduced range of motion and compression that occurs with a painful limb or muscle. That means, training while in pain is going to mess up your mind, especially the part that you are trying to fix that has to do with stabilizing the muscles that are causing the pain and yet another vicious cycle. But at least you weren’t lied to if your chiropractor told you that you needed to get out of pain first before beginning rehab training. 17.
Again, there are lots of studies that back this concept up. Here is another one in case you don’t want to just take my word for it. There is increasing evidence that chronic pain problems are characterized by alterations in brain structure and function. The brain changes can be categorized as neurochemical, structural or functional. Gray matter changes in the dorsal lateral prefrontal cortex, right anterior thalamus, brainstem, somatosensory cortex, and posterior parietal cortex are seen in people with chronic back pain. This means absolutely nothing, I just wanted to type big words. Or, maybe it means that taking ibuprofen and resting in bed is not a very good strategy for that much more serious than you think it is back pain. 19.
And just to destroy your will to live in case I haven’t already, another study puts it this way: Regional cerebral blood flow of the brain using single photon emission computed tomography (SPECT) demonstrated that people with spinal pain had a decrease in cerebral perfusion ranging from 35-45% in the parietal and frontal zones. That can actually make you stupid. That was not the conclusion of the study, but I’m sure I’m safe with that comment. However, the study also noted hyperactivity of the sympathetic nervous system. That is not good because that produces stress hormones and it is pretty well known by now that those hormones are not good for us. 20. This sounds so hopeless, but alas another study revealed that, and by the way that is about at least 4 studies so far just on this that I have mentioned that proves that motor skill training can reverse the brain damaging effects of pain. 21.
A study of neuropathic pain in mice discovered that chronic pain changed the molecular and cellular structures of the hippocampus. The hippocampus region of the brain is predominately known for the limbic system and plays important roles in the consolidation of information from short-term memory to long-term memory and spatial navigation In Alzheimer’s disease, the hippocampus is one of the first regions of the brain to suffer damage; memory loss and disorientation are included among the early symptoms. The limbic system (part of the hippocampus) relates to emotion, behavior, motivation, long-term memory, and olfaction. (sense of smell). One of the first signs of the onset of Alzheimer’s is loss of smell. The volume of the hippocampus was measured in chronic back pain patients.
The study broke down the participants into three groups, chronic back pain, complex regional pain syndrome, and osteoarthritis. The patients with chronic back pain and complex regional pain syndrome had significantly reduced hippocampal regions. These abnormalities may explain the learning and emotional deficits that are seen in such patients. By the way we were taught that brain cells can’t regenerate, but hippocampal cells continually do so. 39. I could say that this provides strong evidence that physical activity is a way to reduce the risk of Alzheimer’s disease, but why should I when there is a different study that specifically states that. 40.
While we’re on the topic of measuring brain function, researchers using PET scans have concluded that chiropractic spinal manipulation creates sympathetic relaxation and regional brain metabolic changes, as well as reduced muscle tone and decreased pain intensity. All this means is, you are getting a big bang for your chiropractic buck, especially if your chiropractor does chiropractic because this study was also performed with a tool and not hands. 41.
So many friends ask me what about acupuncture for their pain. It’s been discovered that interventions that focus on regaining function as soon as possible are more effective than interventions that don’t. Spinal manipulation and rehabilitative exercises has been proven the best way to go. 18.
What do you want to train? Out of all the core stabilizes the transverse abdominis rectus is the smallest muscle. That is the muscle that everyone trains when doing sit ups. By far the side muscles, the obliques provide much more stabilizing qualities. Of course you need to do the extensor muscles on your back as well. Training these muscles on unstable surfaces like you see these days with people on wobble boards is the most efficient way to fire the deep involuntary muscles and to create motor learning in your brain. This in turn helps to improve core stabilization and decrease pain.
If I seem to be saying the same thing over and over again, I am. It’s not easy to break 50 years of myths. Besides, I find it challenging to stumble on new ways to say the same thing. And now I have all this different research that also says the same thing. It is as if I hit the Trifecta of irritation to my friends. While all this impresses yours truly, it may seem very subtle to you, but this is really mind blowing stuff if you are a doctor that treats back pain. The social implications are tremendous and this may one day actually result in real improvements for the world. That means that most of my patients refuse to do these exercises.
O.K. so exercise is your mortal enemy. If we went barefoot, our brains would receive many different kinds of input as we walked over uneven surfaces. Shoes are flat platforms that spread out stimuli, and the surfaces we walk on are increasingly artificial and perfectly flat. This leads us to dedifferentiate the maps from the soles of our feet to our brain and limit how touch guides our foot control. Then we may start to use canes, walkers, or crutches or rely on other senses to steady ourselves. By resorting to these compensations instead of exercising our failing brain systems, we hasten our decline. 22.
I touched on this earlier, but 30 years ago sacroiliac sprains were considered to be just a problem of the ligaments. It turns out that the multifidi muscles are the main stabilizes for the sacroiliac joints. At the other end, the muscles that provide 80% of neck stability are the sternocleidomastoid and the splenius capitis. Chronic neck pain patients demonstrate an overall reduction of neck strength. These muscles are neck stabilizes so the greater amount of activation of these muscles during cervical flexion the overall reduction in general Neck strength.
This is very similar to the mechanisms of low back pain discussed above. Although increased core activation of the neck muscles may be beneficial in acute pain to enhance cervical stability and stiffness by reducing velocity and range of motion, it may also reduce neck strength and contribute to recurring pain by altering the load distribution on the spine and irritating pain sensitive structures. In a nutshell, that means weak neck muscles create neck pain. I mention this because if I see people doing core exercises, they’re usually focusing just on their low back muscles. Just doing isometric exercises for the neck in all four directions helps decrease neck pain. 23.
By now you must be asking yourself, certainly drugs must provide some benefit and it turns out they do not. From the annals of internal medicine, a study revealed that 90% of back pain patients that winded up taking all the categories of drugs, which included NSAIDs, acetaminophen, narcotics, and muscle relaxants all together for that backache, didn’t do as well as the patients who only received chiropractic care. Excuse me while I gloat, but the study also revealed that the chiropractor group had 100% reduction of pain after 12 weeks of treatment. 24.
Another study revealed that patients who received only physical therapy were worse one year after they started. As you would expect the group that were only given drugs were much worse. 25. Diclofenac also known as Voltaren is one of the most common NSAID’s prescribed for musculoskeletal and osteoarthritic pain. A double-blind randomized controlled trial compared the effectiveness of high velocity low amplitude spinal manipulation (that thing that chiropractors do) to diclofenac and placebo. 37 patients received spinal manipulation, 38 diclofenac, and 25 no active treatment. The placebo group had a higher number of dropouts for unsustainable pain and was closed. Both active treatment groups tested significantly better than the placebo group. The spinal manipulation group was significantly better than the diclofenac group. The conclusion was that the subgroup of acute nonspecific low back pain did significantly better with spinal manipulation than NSAID therapy. Keep in mind that last month around April of 2013 diclofenac was on every news report for two days. It turns out the FDA finally decided to warn us that it causes heart attacks. I’m told that hurts more than a backache.
I found this study particularly interesting because I always wonder how they get people to allow this stuff to be done to them. Scientists placed transducers that were in needles between the L-5 S1 vertebrae and into the disc. They discovered that just bending forward 30° increased the pressure on that disc by 360%. If they put 10 pound weights in their hands and had them lean forward 30°, the amount of pressure went up to 430%. Although I said earlier that patients attribute some kind of deliberate action such as picking up a pencil that triggered their low back pain, this study implies that we are carrying a heavy load all day long and flexion (bending forward) is the worst thing that we can do to ourselves. In other words, this is why we have knees, quadriceps muscles, hamstring muscles, and gluteal’s. 26.
In the world of medicine, bending forward from the waist is known as spine hinge. We want to use our hips as a hinge not our spines. Bending forward is one explanation for all the injuries to the low back during yoga. Personally I feel Yoga is the greatest thing in the world when done correctly, but these days not all instructors are created equal. One thing for sure though, the downward dog position does cause negative decompressive force in the lower back and that is a good thing.
Keep in mind, when bending forward, it results in a stress that compresses the anterior disc and that results in a marked increase in tensile stress on posterior ligaments and it is these structures that are highly innervated with pain nerve fibers. A fully flexed spine is 20-40% weaker than if it were in a neutral posture. 27. The loading mechanism necessary to cause disc failure suggests that repeated forward bending causes stresses both in the nucleus and annulus of the disc, resulting in prolapse and herniation. 28.
The spinal discs only have so many numbers of bends before they damage. 29. After sitting the spine is unstable. Ligaments are stretched and the muscles are shut off. A new term relating to this is spine sparing load sharing and that means think about bending your knees to pick things up. Tightening your gut muscles also known as bracing provides significant prevention of back injuries. Pain intensity was reduced in low back pain patients when sitting with lordotic ( arched backwards) versus a flexed lumbar spine. One way to achieve this is to always have your buttocks higher than your knees when sitting. How do you do that? You may have seen inflatable wedges that you can put on your chair, they are becoming popular. Keep in mind that core muscles function differently than the limb muscles in that the core muscles are primarily isometric stabilizes, not prime movers. This means training the core effectively means training them differently than the limb muscles, and Swiss balls are great for this.
Orthopedic surgeons perform a very high tech complex expensive test to determine if the cause of your back pain is from what I just mentioned above. It is called the slump test. If your back hurts while sitting all slumped forward and is helped by sitting up and arching backwards then you had a positive slump test. This indicates that your core stabilizing low back spine muscles are not doing you any good because in a seated position those muscles are turned off. Oh by the way, just kiding it’s not really an expensive test at all although I have seen $300 bills submitted for it.
I guess this paragraph belongs above where I started talking about brain function but it also works down here as well as you will see the connection. A study in the Journal of clinical neurophysiology from 2007 has also discovered that a chiropractic neck adjustment administered to repair dysfunctional cervical joints leads to improved brain function. The somatosensory processing which takes place before sensorimotor integration is improved and contributes to pain relief. Also, there is restoration of functional ability after a chiropractic adjustment. It’s important to realize that episodes of acute pain after injury induce plastic changes (that means the hard wiring in your brain is being changed on a molecular level), these changes process beyond the acute event and go on to alter brain function that stabilizes our spines. All this means is, when left untreated your first injury is setting you up for many more down the line. 30.
One reason why chiropractors want to see you forever is because maintenance care works. It’s not really maintenance at all. It’s supportive care and it is necessary. While I used to make this claim all the time without any scientific proof I can now provide some. A study was designed to give one group chiropractic spinal manipulation without maintenance care and one group received manipulation with maintenance care as opposed to the sham placebo group that received neither. Both groups were significantly better on all outcomes than the placebo group at one month, but only the group that received spinal manipulation with maintenance was significantly better at the 10 month follow-up with reference to all outcome scales. 31.
Deconditioning and fear avoidance beliefs and behaviors also known as deconditioning syndrome are significant factors to predict chronic low back pain. There’s a new category called the active couch potato phenomenon. An example is the office workers that ride their bikes to and from work, but then sit all day at a desk and spent several hours watching TV in the evening. This group spent 71% of their waking hours in sedentary time. It is possible for individuals to be physically active, yet highly sedentary.
As stated above, this shuts off the core stabilizing muscles of the spine and there is a whole new branch of science dedicated to this called inactivity physiology. This new science has discovered that sitting has deleterious biological consequences and not just mechanical problems. The loss of local contractile stimulation with sitting leads to the suppression of skeletal muscle lipoprotein lipase activity. This enzyme is necessary for triglyceride uptake and the production of the good cholesterol HDL. So by sitting all day you are at risk of insulin resistance and reduced glucose uptake. So while eating junkie carbohydrates is considered a main factor for the cause of metabolic syndrome, it appears that prolonged sitting is more dangerous than we ever thought before. How dangerous you ask? Relative to those watching TV less than two hours per day there was a 46% increased risk of all causes of mortality and an 80% increased risk of cardiovascular disease mortality in those watching TV 4 hours per day or more.
Metabolic syndrome is comprised of increased weight, increase blood sugar, increased insulin resistance, increase blood fats, increase blood pressure, resulting in an increased risk of cardiovascular disease and type II diabetes mellitus. These increased risks were independent of traditional risk factors such as smoking, blood pressure, cholesterol level, and diet, as well as leisure time physical activity and waist circumference. Those who reported spending more than 10 hours per week sitting in automobiles (versus less than four hours per week) and more than 23 hours of combined television time and automobile time (versus less than 11 hours per week) had an 82% and 64% greater risk of dying from cardiovascular disease, respectively. 32.
To sum up a review of inactivity physiology, being sedentary causes hypoglycemia, hyperinsulinemia, and hyperlipidemia. 1. Sitting results in no significant contraction of any major trunk or lower extremity muscles. 2. This results in minimal caloric expenditure. Glycogen is stored in the liver approximately 25%, and in type II a and type II b muscle fibers, approximately 75%. 3. Because of exceedingly low metabolic demand in sitting and sedentary activity, glycogen stores are full; therefore, there is increased insulin resistance, cells want no more glucose. 4. Blood sugar and insulin increase, which inhibits hormone-sensitive lipase and prevents the breakdown of stored fat for energy. Blood sugar is converted to triglyceride and stored as fat. 5. Excess blood sugar binds to proteins and lipids producing Advanced Glycation End-Products (AGEs). 6. AGEs clump proteins and block renal tubules-diabetic nephropathy. 7. AGEs adhere to control cells and blood vessels leading to fatty streaks, atheromas, atherosclerosis, eventually leading to cardiac disease, myocardial infarction, strokes, and extremity amputations. 8. AGEs damaged retinal blood vessels resulting in diabetic retinopathy, decreased vision and blindness. 9. AGEs clump proteins in the lenses of the I resulting in cataracts.
Obesity has always been considered to be a factor in osteoarthritis, but it turns out that it is more than just wear and tear. Obesity does increase load-bearing on joints. Forces across the knee are increased three times while walking and six times the person’s body weight climbing stairs. There is an increase in wear and tear on cartilage. Reductions in strength relative to weight, induce fatigue earlier in obese persons, which leads to decreased shock attenuation and increased loading rate.
These effects also occur at a cellular level. Eventually cytokines (signaling molecules) are produced that increase inhibition of the cartilage matrix resulting in degeneration. The newest research demonstrates that a low-grade inflammatory state occurs due to obesity. Excess white adipose tissue (WAT) has traditionally been thought of as an energy depot. However, it is also a powerful endocrine organ that secretes pro-inflammatory and immune regulatory cytokines from adipocytes and adipose tissue lymphocytes. Its endocrine output is directly related to WAT mass. Excess mass causes endocrine dysfunction. WAT is considered to be a pro-inflammatory endocrine organ. It’s secretes cytokines known as Adipocytokines or Adipokines which appear in higher concentrations in the obese. Multiple Adipokines have significant effects on the musculoskeletal system and are associated with elevated inflammatory markers: such as CRP, ESR, IL-6, TNF-a. The pro-inflammatory state caused by obesity is considered to be an underlying cause of metabolic syndrome. Just so you don’t have to look back up the page metabolic syndrome consists of a cluster of conditions including obesity, hypertension, insulin resistance, atherogenic dyslipidemia. These characteristics share common mediators, mechanisms, and pathways.
Many experts believe that osteoarthritis should be considered a part of the syndrome. Osteoarthritis shares the same pathways at a cellular level: oxidative stress, endothelial cell dysfunction, and lipid abnormalities characterized with metabolic syndrome, which is also implicated as causative factors of osteoarthritis, yet another cruel vicious cycle. 42. This is not exactly related, but I find it interesting that we now have non-alcoholic fatty liver disease and that is most likely because fat tissue is a major endocrine organ and produces large amounts of destructive hormones.
How can we fix some of this damage? Prolonged exhaustive exercise training results in hypoglycemia and decreases stored glycogen. Once those carbohydrates are stored as glycogen in muscle tissue you need to get that muscle to use up that stored energy by getting it to burn in anaerobic pathways. Jogging for 60 minutes will not do that. While all the rage has been on aerobic conditioning, the country seems to have developed a whole lot more poor health and if you have been paying attention, the reason why has already been revealed to you. So aerobics while good are not good enough. However, intense interval training will cause us to burn off these stored fats and I highly recommend searching for it on YouTube. Basically it is warming up for three minutes on a treadmill, going as hard as you possibly can for 30 seconds, returning to warm-up level for a minute and a half, then going as hard as you can again for 30 seconds, for a total of eight intervals, and then cooling down for three minutes. The whole thing takes 22 minutes and that sure beats running for an hour.
And now for a little shameless pat on my profession’s own back. Chiropractic was discovered in 1895. Nerve cells were not discovered until approximately 35 years later. Chiropractic has always stressed and insisted their treatment greatly enhanced the immune system. Even though Newsweek had a front page groundbreaking news story in 1987 announcing that the nervous system had an effect on the immune system; this information was not absorbed too well by the experts.
A study in 2012 states that the peripheral nervous system directly and actively modulates immunity, such that the immune and nervous systems may have a common integrated protective function in host defense and a response to tissue injury. 43. This is jaw dropping if you were in medical school for 8 years because you were taught the exact opposite. The true miracle here is, that for over a hundred years, the Chiropractic profession has taken relentless, brutal attacks for believing what is now considered to be good science, that our nervous systems do control our immune systems. One possible reason the medical industry may have reacted so violently against this idea is, because if you knew this, you might not want so many immunizations.
I’ve been adjusted since I was 2 and I think I had one tetanus shot and two polio vaccines back around 1960. I don’t really get sick and even when I have the type of Upper respiratory infection that would have two doctors prescribing 10 antibiotics, I just wait and it goes away, which is now what you are supposed to do anyway. In fact last week, it was discovered that the most popular antibiotic of all, a Z pack, azithromycin, most definitely can cause heart failure.
Being sick is one thing, but there is one thing out here in Hollywood that you can never do and that is to get old. Aging is commonly associated with a loss of muscle mass and strength, resulting in falls, functional decline, and feelings of weakness. A study of quadriceps muscle mass with MRIs discovered that lean mass did not decrease with age despite an increase in total body fat percentage. Strength did not decline significantly with age. It turns out that this study contradicts the common belief that muscle mass and strength decline as a function of aging alone. Instead these declines may signal the effects of chronic disuse rather than muscle aging. This maintenance of muscle mass and strength may decrease or eliminate falls, functional decline, and loss of independence that are commonly seen in aging adults. Keep in mind this study was performed on master athletes so that one sit up that you do between a commercial probably will not benefit you a whole lot. 33.
I am now looking at an amazing algorithm/flow chart of inactivity physiology-deconditioning. While I find it very comprehensive I also find it too difficult to reproduce here. In a nutshell, deconditioning affects most aspects of your physiology and health.
But just how good is chiropractic care you may still be asking? A study where the treatment for stimulating the joints with the use of a mechanical device instead of a chiropractor’s hands demonstrated that there is immediate and significant hypoalgesic effects irrespective of the site that was treated. This means that patients felt less pain not only at the site of pain, but throughout the body. Additionally, there was local muscle relaxation in patients that did not have any pain. Personally, I don’t know why they spent a lot of money on that study, because you can see that on all the happy faces leaving a chiropractor’s office. Its funny how CBS, NBC, and ABC, etc. only seem to find the people who were not very happy with their chiropractor. I wonder if that is because they receive the most of their income from drug companies.
All this great news, but where does the United States spend its spine dollars? From 1999 to 2008, researchers studied the national estimate of mean inflation-adjusted annual expenditures on medical care, chiropractic care, and physical therapy per user for back and neck conditions. 13.6 million people in 2008 went to a practitioner for back or neck pain. The average cost from 1999 to 2008 went up 95% or $487-$950 for the treatment. The study revealed that physical therapy was the most costly service. With population growth, the proportion of all US adults reporting a visit for a diagnosis of a spine condition remained constant at approximately 6%. The mean number of visits for chiropractic was quite stable fluctuating between 7.2 and 9.3 visits per year. That tells us that, chiropractic is the most underutilized treatment in the country even though it is the most effective. 38.
One more time just to hammer home what I think is the smallest point of all this, but, knowing how the typical patient thinks, is very important. How long does chiropractic treatment last with regard to pain? Benefits were seen a year after the last treatment. Don’t forget though, somewhere above, is a study that shows that the more chiropractic treatment you get, the better you are functioning. That means just not, not having pain, but having all your other systems in your body working optimally. Show me a medical treatment that can do that and I’ll show you someone who is lying.
The dreaded Footnotes section:
1. Borkan Fourth International Forum. Spine; 2002 27 (5): E128-132 2. Hayden Best Practice & Research Clinical Rheumatology 2010;24; 167-179 3. Carroll Bone & Joint Decade 2000-2010 task force. Spine 2008;33: 226 articles reviewed. 4. Koes BMJ 2006;332;1430-4 Difficulty Diagnosing causes of spinal pain. 5. Wiesel Is back pain prevention possible? Backletter 2009;23;25, 30-3 6. Suri Spine Journal 2010 (10): 388-395 7. Williams BMJ March 13, 2011 8. McMorland JMPT 2010;33(8); 576-84 9. Solomonow Spine 1999; 24(23):2426-34 10. Solomonow Journal of Electromy & Kinesiology 2012 11. Johnson Journal of Surgical Orthopedic Advances 2008;17;159-64 12. MacDonald Pain 2009;142; 183-188 13. Strutton Journal of Spinal Disorders Tech 2005;18; 420-4 14. Tsao European Journal of Pain 2010;14:832-9 15. Cagnie Manual Therapy 2011;16(470-5) 16. Mayer Spine Journal 2008;8;96-113 17. Boudreau Manual Therapy 2010;xxx;1-5 18. Hurwitz Spine 2008;33:S123-52 19. Wand Manual Therapy 2011;161(1): 15-20 20. Bakhtadze JMPT 2012;35(2):76-85 21. Boudreau Manual Therapy 2010;xxx:1-5 22. Doidge Viking Press, 2007 23. Lindstrom manual therapy 2011:16 (1): 80-86 24. Bronfort Annals of internal medicine 2012; 156:1-10 25. Dusunceli Journal of rehabilitative medicine 2009; 41:626-31 26. Takahashi Spine 2006; 31 (1): 18-23 27. McGill Wabuno Publishers, 2006:134-7 28. Scannell Spine 2009; 34:344-50 29. McGill strength and conditioning Journal 2010; 32 (3): 33-46 30. Haavik-Taylor clinical neurophysiology 2007; 118:391-402 31. Senna Spine 2011; epub ahead of print 32. Owen Science of sedentary behavior. Sport science review 2010; 38 (3): 105-113 33. Wroblewski physiology sports medicine 2011 October; 39 (3): 172-8 34. Kim spine 2010; 35(26s): S281-S286 35. Itz European Journal pain 2013; 17:5-15 36. Zavanela Journal of strength and conditioning Res 2012; 26 (3) 811-17 37. Crownfield dynamic chiropractic 2012 30 (11): May 20, 2012 38. Massaracchio Journal of orthopedic sports physical therapy 2013; 43 (3): 118-127 39. Mutso Journal of Neuroscience 2012; 32 (17) 5747-5756 40. Fox NBC news interview November 2012 with Dr. Cyrus Rajii of UCLA 41. Ogura Alternative therapy health med 2011; 17 (6): 12-17 42. Koonce Journal American Academy Orthopedic Surgery 2013; 21:161-169 43. Chiu Nature Neuroscience 2012; 15 (8): 1063-67
