Chiropractors vs. Physical Therapists

Reminder: If you have not done so, please read the Initial Post and  Blog Information.  At the upper left of this page above my picture click on the button, Initial Post and  Blog Information.

It is fine if you want to see a chiropractor, as long as you understand what he cannot do.  There is no scientific evidence chiropractic manipulation can fix infections, eye problems, heart disease, kidney problems, tumors, etc.  Neither can he rearrange (or adjust) your spine to remove an offending alignment in order to relieve your pain.  An x-ray taken by your chiropractor before adjustment will look no different after adjustment provided the positioning is exactly the same.  (Don’t do this, because the radiation exposure is unnecessary and excessive.  In fact, most people with back problems don’t need x-rays by anyone.  See my blog discussion X-rays, MRIs, and CAT Scans from May 22, 2012.)

However, a chiropractor (or a physical therapist) can stretch soft tissues, like ligaments, tendons, and muscles, to help relieve pain; and he can help patients who are fearful of using their backs understand that they can, in spite of their pain, be active.  Mobilizing a patient with back pain is one of the first steps in resolving the pain.  (See Initial Post and Blog Information – Chapter 1 of What Your Doctor Won't Tell You About Your Lower Back.)

He, or a threrapist, can also use ice, heat, stretches, massage, electrical stimulation, etc. to relax muscles in spasm and to relieve pain.

Taking repeated x-rays, keeping you in therapy for endless periods of time, selling balms or copper or elastic bracelets, etc. do nothing but add to your bill.  This is true whether it is done by a chiropractor, a therapist, or a physician.  Most back pains are limited entities.  Chronic pain may require chronic care, but that is rare.  (Again, see Initial Post and Blog Information – Chapter 1 of What Your Doctor Won't Tell You About Your Lower Back.)

So, if your chiropractor, therapist, or physician insists on a lot of x-rays, repeated visits, months of care, etc., there is a chance that he is lining his wallet and lightening yours or your insurance company's.  Get a second opinion, or maybe read my book, What Your Doctor Won't Tell You About Your Lower Back.

Pain

The are several ways to classify pain.  Two ways of describing pain are generally used to define low back pain.  The first is centered around acuity.  Acute pain is pain less than 6 weeks in duration.  Subacute pain lasts from 6-12 weeks.  And chronic pain is defined as lasting more than 12 weeks.  These divisions are arbitrary, but they help the physician decide what the chances are your pain will diminish on its own.

Another clssification has to do with the way your brain perceives pain.  If you are receiving pain from pain receptors within your body, then that is called nocioceptic pain.  Non-nocioceptic pain information is sent by nerve fibers not attached to pain receptors.

Nocioceptic pain can be visceral (from organs) or somatic (from the rest of the body).  Non-nocioceptic pain can be neuropathic (peripheral nervous system) or sympathetic (from the parasympathetic nervous system).

Most back pain  is sent by pain receptors: it is somatic and nocioceptic.  Some back pain is neuropathic (sent by compressed nerves).  That pain is non-nocioceptic.

Each type of pain has a characteristic pain pattern.  The patterns are not 100% reliable, but they help the physician decide where the pain originates.

To help delineate patterns, the doctor will also ask you to describe the pain: sharp, dull, squeezing, buring, itching, etc.; if the pain is steady, intermittent, or occasional; how long it lasts; and how long periods without pain last.  In addition, he will want to know how severe the pain is and if it radiates (travels) to different places, what makes it better or worse, and what triggered the initial occurrence.

The difficulty in diagnosis usually occurs when there are multiple sources of pain, or the patient is unable to describe the pain.  It's not easy to tease out the information sometimes.

Back Surgery

This posting is early.  First time that has happened!  The grandkids will be here next week.  Don't think I'll have time to make a post between entertaining them at the beach and pool, or sight-seeing.

Surgery has a very limited role in the treatment of back pain.  Although it is probably offered to patients more often than is necessary (this is, after all, how surgeons make their living), there are a few good reasons to have surgery.  A small number of surgeons think the only way to cure a medical condition is with cold, hard steel.  There are also some surgeons whose only interest in the patient is in the fee they collect; they collect more for doing surgery than for talking patients out of surgery.  Honest, ethical surgeons give the patient options and honest opinions.  The problem may be in figuring out who is being honest and who isn't.

Most insurance companies, especially workers compensation companies, would prefer not to pay for surgery, or long term rehabilitation instead of, or following, surgery.  The less they pay out for procedures or physical therapy, the more profit they make.  Stock holders like that; patients don't.  And if insurance companies can find a way to no longer be the financially responsible party, all the better.

Keeping the above two paragraphs in mind, some times surgery is a necessity.  Statistically, necessary surgery probably falls in the range of 5% of cases.  In another 5% of cases surgery may be appropriate because it saves the patient healing time and time off work, even if it does not affect the eventual overall outcome.  This means that in 90+% of back pain cases, surgery is not needed!  All surgery has the potential for complications, from pain to numbness to paralysis to death.  Think hard about your choices.

In general, a patient needs surgery when surgery can save his life, repair an injury the patient’s body cannot, or shorten significantly the recovery from an injury or disease.  When it comes to the lower back, there are five absolute indications for surgery, but several elective reasons.  The absolute indications for surgery are the following:

1.  Cauda equina or conus medullaris syndrome.  These situations happen when there is a very large central herniated disc that compresses severely the nerves in the lower spinal cord.  Without surgery, the compression would lead to eventual loss of function of those nerves, paralysis of muscles, and/or loss of sensation.

2.  Intractable pain, i.e. unremitting, severe pain.

3.  Progressive neurological deficit, loss of sensation, proprioception, muscle control, etc.

4.  New incontinence or retention, bowel or bladder.

5.  Hemorrhage into the spinal cord.

The relative indications generally center on the relief of discomfort (less than intractable) and the shortening of recovery time from various problems: herniated disk, compression fractures, severe stenosis, severe spondylolysis, and severe spondylithesis, etc.

There are also several types of surgery: open, micro, and minimally invasive (and endoscopic).  Open takes less time, usually.  The surgeon has a better view of the surgical field, but more structures are damaged and recovery is longer.  Micro surgery takes longer; the field of view is smaller, but fewer structures are damaged and recovery is shorter.  Minimally invasive surgery, in general, takes the longest; is the most difficult; has the narrowest field of view, but the shortest recovery time.  There are trade-offs.  Get the surgeon to explain them all to you.  If he can't or won't, find another surgeon.

If someone uses the words, laser surgery, he is trying to impress you.  Nothing more.  Lasers have their place in surgery -- usually cauterizing blood vessels.  Very little surgery is done with a laser.  A laser produces too much heat.  Laser is a buzz word only.  And the person using it is a salesman first  -- surgeon second.  He wants your money; he's not concerned with your best interests.

Decompression

Decompression is the opposite of compression.  Bulging discs, arthritis, inflamed or thickened ligaments, or combinations of these entities can compress nerve tissue causing pain in the lower back.

There are multiple ways of decompressing, or relieving this compressive force.  The most commonly known way is surgical, either non-invasive or micro-discectomy, or laminectomy.  Since only 3% of herniated discs and a slightly larger percentage of stenotic spines benefit from surgery, non-surgical methods of decompression have been tried.

Most of the non-surgical forms of decompression involved traction (stretching) of the spine.  An attempt is made, either by hanging upside down or right side up, or by supine traction, to stretch the spine.  The theoretical goal is to increase the distance between the lumbar (lower back) vertebrae.  This would (again, theoretically) cause the protruding disc or nucleus propulsus to be sucked back into the annulus and to increase the flow of nutrition to the nucleus and annulus to promote healing.

Unfortunately, none of this has been proven to happen, or to be effective.  Long term, studies suggest that the pain relief achieved is no better than physical therapy in general.

Vax-D, Inversion Therapy, Antalgic-trak, IDD, or traction by any other name can be expensive, and not very helpful.  Save your money.