Chiropractic is often described as a package of care consisting of manipulation or mobilisation techniques, exercise prescription, ergonomic and lifestyle advice as well as general health and wellness advice.  Often our role overlaps with counselling as we talk with someone about losing a job, stress management or relationship issues. All of these can, of course, have an impact on general health and even back pain.

Many studies have looked at how to predict who will get back pain and who won’t. Unfortunately most research doesn’t come up with a worthwhile answer except in one area – psychology. Asking someone if they like their job or if they like their spouse or partner is quite useful to predict who is more likely to get back pain. If someone answers no to either question then they are more likely to get back pain than someone who answers yes. So counselling is an important if more amateur part of a chiropractors job than seeing a trained psychotherapist. We often refer people to  psychotherapist if a brief chat is not really going to be enough.

You can ask does the package of care compare well to another package of care. This is what the the Medical Research Council asked in 1990. They found that chiropractic care was 70% more effective than conventional medical care in the treatment of back pain. It was a pragmatic study, that is, all the chiropractors, doctors and physio’s were allowed to do whatever treatment they would normally do. Of course the physio’s hated the results and criticised the study heavily.

In a repeated study the professional rivalries were reduced by looking at the treatment interventions themselves, especially manipulation and exercise compared to drug therapy. The BEAM trial in 2005 showed that for back pain exercise is good, manipulation is better and that manipulation and exercise is best. Drug therapy did not do so well.

This was a good lesson for chiropractic or more particularly for chiropractors themselves. It meant that we cannot own a particular treatment modality, in this case – manipulation. Physio’s and osteopaths were also involved in the trial and showed they they had skill in manipulative care too.

As the market place for spinal care gets more crowded some chiropractors have sought to distinguish what they do from other health providers by stating their belief in the value of treating the vertebral subluxation complex. The origins of this rather archaic and vague term dates back to the inception of chiropractic as a profession in the 1800′s and has different meanings in medicine. Most chiropractors registered with the British Chiropractic Association prefer to describe the spinal problems that we treat in terms of biomechanical and neurological dysfunction that any medical doctor would understand. It is the same problem described differently.

Another difference is between mainstream chiropractors and the ones from the past is the the concept of disease being caused by these subluxations. Whilst there is some interesting evidence, we are a long way off being able to show that treating spinal dysfunction will help with health and disease in general. A comparison can be found with old fashioned ideas of the causes of disease in medicine in general. Until the nineteenth century the concept of the four humours of black bile (melankholia), yellow bile (cholera), phlegm (phlegma), and blood (sanguis) as the cause of all ill-health was widespread. Conventional medicine dropped these concepts as more became known.  Interestingly cholera survived as a description of a different entity.

If chiropractic is to fulfill its role as the specialist provider of non-surgical spine care, working alongside mainstream health care we will have to resolve this dichotomy and explain our role as a profession not just a treatment. We will have to use universally understood terminology and apply evidence informed care for the best interest of our patients.

Watch your back

At this time of year I start to see several people who have injured themselves on holiday. It is not the sort of holidays that you might expect either. Rather than activity holidays like biking, kayaking, tennis and walking trips it is the inactivity holidays that are worst culprit. As stress builds leading up to the departure date, aches and pains start to recur before people even get to their destination.

Even packing can cause back pain. Getting cobweb laden suitcases out of lofts and cupboards often means twisting into tight spaces. Bending over repeatedly to pack holiday essentials also aggravates the back muscles and joints. The dash to the airport, lugging heavy bags out of the boot of the car and on and off trolleys can be troublesome. Standing in a check-in queue for hours at 5 am can play a part too.

Travelling is rarely a pleasure especially if you are crammed into an aircraft seat designed for someone who is obviously six inches shorter than you are. A few hours sitting still whether it is in a plane, train or car will often cause even a healthy spine to stiffen a bit. Combine that with the contact sport that is the luggage carousel and conditions are ripe for a back strain.

Finally you arrive at the hotel or apartment only to find beds that are too hard or too soft and a pillow that is worn out. Then there is more bending to un-pack. You have completed a spinal assault course and you have only just arrived.

Sunbeds are another hazard for the unsuspecting. Lying still for ages, especially on your front, can aggravate a stiff back. Combine this with unaccustomed activities such as splashing about in the pool or sea, sailing, windsurfing or even banana boat rides and conditions are  perfect for aches and pains to start.

There is one more obvious danger lurking – sunburn. The usual preventative steps are well-known – a hat, sunscreen and staying out of the hottest part of the day but there is a little known secret that can help prevent sunburn. Omega 3 essential oil supplements.  Omega 3 oils help protect the skin against sun damage and will work best when used with the other prevention measures.

Top Tips to prevent holiday aches and pains

1. Pack well in advance to avoid the stress and place the suitcase at a suitable height to reduce bending.
2. Get help lifting bags and bend from the knees rather than the waist.
3. Use wheeled cases or buy a separate lightweight luggage trolley.
4. Use a ruck sack rather than a hand carrier.
5. Take an orthpaedic travel pillow.
6. Take Omega 3 oils for two weeks before departure and whilst away.
7. Fold a jumper behind your back for support when in a poor seat.
8. Put a duvet under you on a hard mattress, put a soft mattress on the floor.
9. Don’t lie on a sun lounger for more that half an hour and for no more that 15 minutes on your front
10. Book a spine check with a chiropractor if you are having any pre-holiday niggles.

If all else fails fly first class and get your butler to carry the luggage. Have a great trip.

Joints have a sack around the ends of the two bones which make up the joint and this sack, or joint capsule, is filled with lubricating fluid produced by the lining of the capsule itself. As with all fluid there is a certain amount of gas dissolved in it. When the joint is pulled apart rapidly the volume of the joint increases but the joint capsule won’t let any more air in so a vacuum is created. This drop in pressure is what is thought to allow the dissolved gas to escape from the fluid into the joint. At this point the joint volume increases suddenly with snap and this is what we hear. Once a joint has clicked it won’t click again until the gas has dissolved back into the fluid about 20 minutes later.

There are a couple of other causes of apparent noises coming from the joints too. Tendon of muscles can snap over bony prominences as you move. This happens especially in the wrists, shoulders, hips and ankles. It is not actually occurring in the joint itself but outside it and is usually totally harmless. A key difference with true joint clicking is that it will occur repeatedly without the 20 minute wait between clicks as no gas needs to dissolve back into any fluid.

The third causes of joint noise is the most ominous. Arthritis, particularly the wear-and-tear type – osteoarthritis. Here the noise sounds more like ground glass in the joint. It is a crunching, grinding type of noise which may gradually lessen with repetitive movements. It is caused by roughening of the joint surfaces so they are unable to slide over each other silently any more. It is a bit like the non-stick surface coming off a frying pan. The joint becomes a bit sticky.

We notice noise in the joints of the neck more than any others because our ears are nearby. The other big joints like the knees also sound loud because they are so big. Other people will often notice these clicks too but it usually not a sound associated with arthritis.

Can regular joint clicking cause arthritis? When done in moderation is unlikely to cause any harm. If it associated with normal movements then clicking has never been identified as a cause of arthritis. If you are a regular finger clicker this too is unlikely to be bad for you. One survey in a retirement home found regular finger clickers were less likely to have arthritis.

Some people worry that regular chiropractic adjustments may cause joint damage. This has never been shown and in fact the reverse is likely to be true. Joint stiffness which chiropractic treatment removes can cause wear-and-tear changes in as little as 2 weeks.

So if U2 Inc. can suffer from losses due to back pain it is no wonder that sick leave costs firms an average 9% of their overall wage bill each year(i), it makes good business sense for any organisation to take a proactive approach towards employee health.

Studies show employees get back to work 4 times faster using chiropractic care than medical care for back pain(ii). Also healthy employees work better as a team, work better for the company and work better for longer — helping avoid colossal sick-pay budgets, lengthy sick leave and rising health insurance premiums. And that in turn leads to improved retention and recruitment of high-quality staff.

Put simply, investing in good health-risk management can be a major contributor to the success of the business.

As one of Brighton’s most established health clinics, we have been carrying out free staff evaluation in their offices. It has been going down really well. Each consultation takes about 15 minutes and includes:

·         Back and Neck Check-Up

·         Posture Evaluation

·         Ergonomic advice

·         Treatment options

Our aim is to massively reduce absenteeism. But it is not just back pain we have been asked about.  Nagging headaches, crippling neck and shoulder pain, hand and wrist pain, hip and leg pain have been common. Pain need no longer be a barrier to a healthy, productive workforce.

So if U2 want me to do a workplace assessment, please get in touch.

i According to research carried out by the Institute for Employment Studies

ii Chiropractic Journal of Australia – 1992;22:47-53

Recently NICE recommended against the routine use of x-rays for simple low back pain. As far back as 1976 studies(1) showed that ordinary x-ray films don’t show the cause of the pain. Further arguments showed that in most cases and doesn’t improve care or the clinical outcome.  Whilst that may be true for medicine where the first treatment is medication and then, after a while, physiotherapy exercises, chiropractors use x-rays differently.

The 1976 study was limited to the 18-50 age group so the same conclusion cannot be drawn for older back sufferers. Chiropractors take films standing up which shows such things as leg length differences far more accurately than measuring the legs or eyeballing differences at the feet or ankles. Hospitals take back x-rays lying down which show disease but mask postural changes like spinal curvature (scoliosis)  and disc compression with instability.

Chiropractors main form of treatment is manipulation or adjustment of the spine. Whilst this is a safe procedure in most people, if you have a hidden spinal birth defect, x-ray can show if it safe to adjust. Chiropractors feel for individual spinal bone movement and it is the loss of this movement which is thought to cause many forms of back pain. If there is a spinal defect where 2 vertebra have not  grown properly and have fused, which is not uncommon, then that segment will move abnormaly. Without an x-ray a chiropractor might conclude that this was 2 bones locked together causing the pain and start treatment to unlock them. In a review of 847 x-rays form new borns to 85 year olds, 68 % had observable anomalies (2).  These ranged from common wear-and-tear arthritis to tumours and fractures. It is good to know so that the right treatment can be applied.

Are X-rays Safe?

We are exposed to x-rays every day, about 2.4 mSv a year. In Cornwall the rock emits more radiation so it is bit higher here ( no Cornish jokes please). When we fly the exposure is higher still. It has been assumed that any exposure is harmful. This has not been based on research but an assumption that the effects are linear down to zero. This theory means that even small doses have a small adverse effect.

But is this true. In 2008 Rodgers and Holmes (3) went to Chernobyl to find out. Astonishingly they found that at small doses of up to 15 mSv, x-rays were actually beneficial! Up to this level people had lower levels of cancer than a normal un-exposed population. So x-rays are good for you, within reason. A set of 2 low back x-rays is about 1 mSv (4) and the maximum safe dose is 20 mSv a year (5).

The British Chiropractic Association insists on a strict code of practice to ensure even higher safety standards. Regular site inspections and equipment maintenance is carried out to make the best use of a valuable resource in the chiropractors diagnostic options.

References

1. Nachemson, A. L. (1976). The lumbar spine an orthopaedic challenge. Spine, 1, 59-71.

2. Beck, R. W., Holt, K. R., Fox, M. A., &  Hurtgen-Grace, K. L. (2004). Radiographic anomalies that may alter chiropractic intervention strategies found in a New Zealand population. Journal Manipulative Physiological Therapeutics, 27, 554-9.

3. Rodgers, B. E., &  Holmes, K. M. (2008). Radio-adaptive response to environmental exposures at Chernobyl. Dose Response, 6, 209-21.

4. Wall, B. F., &  Hart, D. (1997). Revised radiation doses for typical X-ray examinations. Report on a recent review of doses to patients from medical X-ray examinations in the UK by NRPB. National Radiological Protection Board. Br J Radiol, 70, 437-9.

5. World Nuclear Association (2009). Radiation and Nuclear Energy. Dec 2009 from  http://www.world-nuclear.org/info/inf05.html

Where things get a bit murkier is where the evidence is inconclusive or negative. Conditions here include some treatments for neck pain, colic asthma and period pains amongst other things. And here is where I have a problem. I know some of my patients get relief from sciatica which is included in the inconclusive list. So am I deluding myself, are my patients deluding themselves that a few minutes of my time once or twice a week is having a placebo effect or is the research not telling the whole story.

The trouble with an RCT is it must limit the variables to accurately test whether one intervention is better than another. It must strip away many aspects of what we do as chiropractors and boil it down to a single thing, in this case manipulation. It is a bit like studying drilling in dentistry. It will be good at sorting out dental carries but not so good at sorting out gum disease perhaps. But to say that dentistry cannot treat gum disease is obviously nonsense. Some will say that chiropractors cannot treat sciatica based on this study and that is nonsense too. The study says that manipulation on its own, which can be done by BCA  chiropractors, physio’s, osteopaths and even medical doctors with a few days training, is not shown to be effective. It is not shown to be ineffective so there is some evidence but not enough. But what if the manipulation was combined with exercises, lifestyle modification, counselling, back to work advice, and in the case of the medical doctor, drugs. What would the outcome be then and how would you test it? It would be difficult to use an RCT and instead a more practical, pragmatic trial would be better suited. This would have been excluded in this study.

So I take from this work that if an RCT says it works then it probably does. If an RCT says it doesn’t work then I look at evidence from second tier trials. If the evidence is substantial then I am happy to treat accordingly. If the evidence is not good but I have seen successes in the past I may recommend a trial course of care and keep a close eye on that particular patient is responding using objective functional tests where possible.

]]> http://sundialchiropractic.wordpress.com/2010/02/13/let-food-be-thy-medicine-or-how-food-can-reduce-inflammation/feed/ 3 sundialchiropractic Choice, apple or a cake? http://sundialchiropractic.wordpress.com/2009/12/19/arthritis-and-shock-absorbing-insoles/ http://sundialchiropractic.wordpress.com/2009/12/19/arthritis-and-shock-absorbing-insoles/#comments Sat, 19 Dec 2009 20:26:15 +0000 sundialchiropractic http://sundialchiropractic.wordpress.com/?p=79 Continue reading →]]> If you are suffering from arthritis in your feet, knees or hips you should try wearing shock absorbing insoles- or so say NICE the nhs guideline body. Apparently insoles,  footbeds or orthotics as they are often called help by aligning the foot and ankle properly and reducing the loads placed on sore joints. Even low back pain can improve but the research is less clear on this effect.

Often orthotics are used to correct over-pronation or flattening of the arches in the feet. If the arch flattens the foot rolls inwards and takes the shin bone or tibia with it. This puts more strain on the knee and hip and may be one reason footbeds work so well at relieving pain in these joints.

How to choose an insole

As with so many things the cheapest is not necessarily the best. There are simple foam inserts that are available from pharmacists and walking shops but these generally are not up the job. When our heel hits the ground in a normal stride the large forces overcome the foam support and it is rendered useless.

A much more expensive option is to have an orthotic custom-made by a podiatrist. Interestingly this may not be any better than an off-the-peg footbed. Some research says that a bespoke orthotic, costing upwards of £200 does not perform any better than the best £30 ready-to-wear option.

I have been using the ready-made Superfeet footbeds for years, both personally and for my patients. I find that they are best for most people with straight foward normal feet. Good fitting of Superfeet is the key to getting the best from them. So make sure that a good walking or skiing shop fits them or come in and ask us to do it.

So what is the difference Adrian, the journalist, asked. The main things are some subtle differences in the spinal techniques used and probably most important of all – chiropractors will recommend preventative check-ups more often. Whether this is appealling to you depends on whether you like idea of preventing future episodes of, for example, back pain. If you go to a dentist for check-ups you probably like the idea of preventative chiropractic too.

There are a couple of other differences between chiropractors, osteopaths and physios. An important one is that chiropractors are qualified to take and read x-rays. We have an x-ray unit on site.

There are about 2500 chiropractors in the UK. Osteopaths number about 4000. In the rest of the world the situation is reversed with about 60,000 chiropractors and about 10,000 osteopaths. The difference in the UK is probably because there has been an osteopathic college here since the 1920′s but a chiropractic college only since 1965.

There are about 40,000 physios, mostly working in the NHS, whereas almost all osteopaths and chiropractors work in private practice. In the last few years, however, there are several Primary Care Trusts in the NHS employing them. Indeed the 2006 Department of Health Musculo-Skeletal Framework recommends that this should be more common. The NICE chronic back pain guidelines published in June 2009 back up this view.

The difference between chiropractors and physios boils down to spinal manipulation. Whilst a few physios do go on to gain a qualification in manipulation most don’t and it is not taught at an undergraduate level to any great extent. Physios do spinal mobilisation which is less vigorous and less effective for things like back problems in my view.

Physios will tend to do more work on extremity problems like frozen shoulder and tennis elbow and other pulls and sprains. They are very good at this and use exercises and machines like ultrasound and in our clinic laser therapy which is wonderful.

So what went wrong? The joints of the neck get compressed when you look up and, if you are vulnerable to neck injury, the joints get inflamed leading to pain. The muscles can then tighten up causing more pain and sometimes the nerves get irritated too.

Fortunately these two clients had a fairly straightforward locking of a couple of the neck vertebrae. I adjusted the bones and they both felt immediate relief. I suggested it would need to be done a few more times over the next week or two to complete their recovery.

Neck pain is common and, until recently, little was known about the effectiveness of various treatments for it. A recent report by an international medical science group (1) identifies what works and what doesn’t. It took seven years to complete and summarised more than a thousand studies to compile its findings. It is the most comprehensive study into headaches, neck, shoulder and arm pain ever undertaken.

The key findings for mild neck pain are that manipulation, as done by chiropractors, is safe and effective. Exercises, acupuncture, pain-killers, massage and laser therapy are also equally effective. It was found that the treatments most unlikely to help are surgery, collars, ultrasound, TENS, most steroid injections into the neck joints and numbing the neck joint nerves with radio-frequency therapy.

There is only one thing for it – watch fireworks lying down.

(1) Haldeman S, Carroll L et al, (2008) The Bone and Joint Decade Task Force on Neck Pain. Spine 33(4S).