Spinal Manipulation versus Diclofenac for Low Back Pain

Prevalence of low back pain is between 31% - 47 % in the general population.  80 % of patients with acute low back pain who receive treatment return to work within one month, but that 7 % can develop chronic low back pain.  On the other hand, more than 60% of people with acute low back pain who do not receive treatment develop chronic low back pain or have reoccurrence.  Therefore, proper and early treatment appears to avoid the transition into chronic low back pain. 

A 2013 clinical trial published in Spine compared Spinal Manipulation Therapy (SMT) to the nonsteroidal anti-inflammatory Diclofenac  (NSAID) for acute, non specific low back pain.  A total of 101 patients with acute low back pain (LBP) for less than 48 hours were recruited.  The subjects were randomized into three groups:

Group 1: Spinal manipulation, placebo diclofenac

Group 2: Sham manipulation, diclofenac

Group 3: Sham manipulation and placebo diclofenac

Outcomes were measured by a blinded investigator that included self rated physical disability, function, time off work, and rescue medication during the 12 week study.  The double placebo group 3 had a high number of dropouts due to unsustainable pain, so that group was closed before the end of the trial.  Comparing the two active interventions, the manipulation group was significantly superior then the diclofenac group, with no adverse effects recorded.  Subjects reported a better quality of life after spinal manipulation compared to diclofenac and patients in the NSAID group took almost three times as much rescue medication compared to the spinal manipulation group. 

Citation:  Spinal High Velocity Low Amplitude Manipulation in Acute Nonspecific Low Back Pain:  A Double Blinded Randomized Controlled Trial in Comparision with Diclofenac and Placebo.

Von Heymann, et al.  Spine 38(7)540-548, April, 2013

Musculoskeletal Effects of Cigarette Smoking

It is well known that cigarette smoking is implicated in lung cancer, respiratory conditions, cardiovascular disease and impaired immunity.  Heavier smokers (over a pack a day) also create a hypoxic state (lack of oxygen) in the body, which can be attributed to other health issues.  Researchers reviewed the current literature to specifically look at the effects of cigarette smoking on the musculoskeletal system and here are some of their findings: 

Bone Metabolism and Fracture Risk: Smoking appears to affect both osteoblasts and osteoclasts, both of which are important for balanced bone health, and can lead to a decrease in bone mineral density (osteoporosis).  This leads to an increased risk of fracture of the hip, spine, and radius. 

Fracture Healing:  Smoking leads to reduced blood supply and local tissue hypoxia, which increases fracture healing time, and increases the risk of poor healing, infection, and non union of fractures. 

Soft Tissue Healing:  Smokers tend to have delayed wound and soft tissue healing of tendons and ligaments, a higher risk of tendon injuries, increased wound infections and complications compared to non smokers.  Smokers have been shown to have a higher incidence of rotator cuff tears.

Back Pain:  The increased levels of pro inflammatory mediators by smokers can amplify pain as well smoking appears to be associated with an increase risk of degenerative disc disease and low back pain.  However, it is difficult to say how smoking is associated with low back pain, as smokers often have worse health, both mentally and physically, than non smokers. 

Arthritis:  There is an unclear relationship with smoking and osteoarthritis as some studies have shown increased knee cartilage loss in smokers, but it is an accepted risk factor for rheumatoid arthritis.  Smokers have also been shown to have a greater chance of developing lupus, an inflammatory autoimmune disorder.

Perioperative Management:  The negative effects of smoking on wound healing appear to improve after 4 weeks of smoking cessation.  Former smokers tend to do better than current smokers in terms of improved recovery from surgical wounds and have less post operative complications.  It would therefore be highly recommended that smokers cease smoking at least 4 weeks prior to any surgery. 

There are many health reasons to quit smoking, now we can add musculoskeletal conditions to the list!

Citation: Lee et al, The Musculoskeletal Effects of Cigarette Smoking; Journal of Bone and Joint Surgery (Am) 2013; 95: 850-859.

Exercise for Metabolic Syndrome

Metabolic syndrome is made up of five conditions: hypertension, diabetes, hypercholesterolemia, hyperlipidemia and obesity.  There are commonalities among these conditions, so treatment can have an effect on more than one condition in the syndrome.  One such treatment is EXERCISE aimed at weight loss.  Most health care providers understand the benefits of exercise, and often suggest to patients to exercise and lose weight, but they provide minimal instruction on how to do this. 

Aerobic training is the easiest type of exercise to begin with, and once started other components can be added such as flexibility and strength training.  Due to the often poor health status of the person with metabolic syndrome, it would be recommended that a physical exam be conducted before an aerobic conditioning program is started.  Blood pressure, pulse rate, body weight and circumferential measurements of the waist, hip and thighs should be recorded to establish a baseline. 

Aerobic exercise is anything that can elevate your heart rate.   Walking indoors or outdoors, walk/run intervals, running, stair climbing, water aerobics, swimming, rowing, jumping rope, cycling on a stationary bike or outdoors, and dancing are activities that are aerobic.

Exercise can be recommended as a number of sessions a week for a certain length of time, and should be referred to as a prescription, as patients are more inclined to see it therapeutically to treat their metabolic syndrome.  Monitoring is important, for motivation and compliance as well to determine if there are any concerns to address.  Depending on the patient’s pre-existing conditions, assessments should be done monthly if they are just beginning or returning from an injury, but patients who are in better shape or have been exercising longer may have a longer period between assessments.   

The rule for determining minimal intensity is that the patient must be sweating within the first 10 minutes of exercise, and maximum intensity is that the patient must be able to carry on a conversation while exercising.  Another method to determine intensity is to monitor heart rate.  To determine a patient’s target heart rate, subtract the patient’s age from 220 than subtract the resting heart rate from this number.  To burn fat, the number is multiplied by 60-70 percent, for endurance the number is multiplied by 80. 

The final step in aerobic exercise is to keep track of activity by recording duration and dates of exercise sessions.  This helps with compliance and to determine progress.  Of course, exercise is always more fun when you do it with someone else, so get family and friends to join you! 

Unique Characteristics of the High Arch

When it comes to abnormal foot mechanics, a pronated or flat foot is the most common condition, but there is a smaller minority or people that have a high arch or supinated foot which can equally cause problems in the lower extremity.  An elevated arch tends to transmit rather than absorb shock as it is very rigid and inflexible, this results in increased forces up the kinetic chain to the knee and hip, making it susceptible to stress fractures of the foot and leg.  A study reported in Clinical Biomechanics found that high arched subjects had increased leg stiffness and vertical loading rates compared to low arched runners. 

While athletes with excessive pronation or supination of the feet are susceptible to more knee injuries, they differ in the type of injury patterns.  High arched runners report more lateral knee injuries, as they tend to be more bow legged, as opposed to low arched runners who show more medial knee injuries as they are knocked kneed.  Stress fractures in the calcaneus and seasmoids bones of the feet are more common in high arches, whereas soft tissue injuries are more common in low arches.  High arched runners experience more lateral ankle sprains and iliotibial band problems, while low arched runners have more medial meniscus and patellar tendonitis problems. 

A high arched foot generally requires improved flexibility (mobilization/stretching) of the foot and stabilizing orthotics to help decrease the shock at the heel strike, absorbing some of the forces and minimizing transmission up the leg.  These components would help to reduce the injury potential of the rigid foot with associated knee injuries, particularly in the case of runners, as running multiplies the forces three times more on heel strike.   

The unique nature of a rigid, high arch was recently reinforced to me when I had a patient who had one high rigid foot, and requested fitting for orthotics.  Her history included being a runner in the past and suffering a calcaneal stress fracture and a long history of iliotibial band issues on the rigid foot side, both conditions associated with a high arch.  

Plantar fasciitis and heel spurs can occur with both a pronated or supinated foot, due to the abnormal structure and pulling on the fascia.  Treatment is similar with both of these conditions, which can include ice, cold laser, mobilization, stretching, and orthotics.  Just as with a low arch, a person with a high arch will have to take extra care of the feet and have good foot wear for life. 

Restricted Carbohydrate Diet

In order to obtain and maintain your ideal body weight there is no magic bullet.  Obviously getting rid of processed food in your diet and increasing your veggie and fruit intake are  essential, as well as weight training to preserve lean muscle mass and cardio to burn fat stores.  The controversy seems to be in the low or no carbohydrate diets that are the current fad.

Weight loss without carbohydrate restriction is very difficult for most people.  When you eat a carbohydrate compared to a protein or fat, it is broken down rather quickly into glucose.  Once your bloodstream is flooded with glucose from your meal, insulin has to be released to make the energy accessible to the cells, but if there is excess glucose floating around, it gets stored as fat.  There is a strong correlation with type two diabetes and high carbohydrate diets, as when there is a constant stimulation of the pancreas to release insulin to process the excessive glucose, it eventual “wears out”.

So what does carbohydrate restriction mean?  One gram of carbohydrates equals four calories.  Many low carbohydrate diets reduce carbohydrate consumption to 20% or less of your diet, but a restricted carbohydrate is a more realistic 30% of your total calories from carbohydrates.  So if an average woman eats 1200 calories a day, than no more than 360 calories should be from carbohydrates, or roughly 90 grams of carbohydrates.  The change to a diet with reduced carbohydrates would put the body into ketosis, and shift the focus of energy from the immediate glucose available in the bloodstream to ketones, thus accessing fat stores to lose weight. 

There has been much research in the field of restricted carbohydrate diets. The New England Journal of Medicine published a clinical trial in 2008 comparing a low carbohydrate diet versus a low fat diet in obese patients and found that the low carbohydrate diet produced increased weight loss, decreased triglycerides and increased insulin sensitivity as opposed to the low fat diet. 

So the bottom line is start cutting back on your processed grains, such as bread, pasta, rice, cookies, pastries; and critically look at the nutritional information on all processed foods for the carbohydrate count.  Make sure any of the carbohydrates that you do consume are of high quality, preferably whole foods such as fruit and veggies and whole grains. 

Balance Exercises to Reduce Falls in the Elderly

As our society grays, it will become more important to avoid a health care crisis if a focus can be kept on keeping the elderly living in their own homes as independently as possible for as long as possible.  One of the largest sources of injury and hospitalization is from falls in seniors.  If the result is a hip fracture, there is a 50 % chance of permanent mobility issues that may result in the senior being unable to return to their home. 

Exercise is touted as one of the best preventative measures to not only reduce cardiovascular disease, type two diabetes and certain cancers, but to also stave off the progression of unhealthy aging, such as loss of muscle and bone mass; less flexible joints and reduced elasticity of tendons and ligaments.  One of the biggest barriers to exercise in the senior population is the fear of a fall, hence often the best strategy to get seniors moving is to start with restoring their balance to reduce this fear.  Balance is a function of input to the brain from information gathered in the vestibular (inner ear) system, visual system and somatosensory system (muscle, joint and skin receptors). 

There are a lot of exercises that can be used to enhance the balance of seniors, but they should all be done supervised and graduated within limits of the senior’s abilities.  There should always be a support available to the senior, such as a chair, wall, or counter to give the senior stability and confidence to perform the exercises.  Most balance exercises can be performed at home with little to no equipment needed, making it very cost effective.

One of the simpliest balance exercises to start with is by standing on one foot, while hanging on to a support.  Progression can be made to letting go of the support, but keeping it in reach if needed.  Once this has been mastered, the next step is closing the eyes, thereby removing the visual input, and having the mechanoreceptors in the muscles and joints to work harder.  

Another simple balance exercise is to go to the corner of the room, and with the two walls as support, place one foot in front of the other, keeping the weight is on the back foot.  This is challenging as it narrows the base of support for the body, as many seniors start to develop a wide stance to compensate for their lack of balance.   Again, the further challenge would be to not touch the walls, but keep the hands out for support if needed, and then to progress to closing the eyes. 

The internet is filled with websites on balance exercises, and another source would be the health district and senior centres, which may offer supervised classes.  So to keep the seniors in your life independent longer, think about doing some simple balance exercises and encourage them get more active. 

Cold Laser Post Knee Replacement

With an aging baby boomer population that have been more active than past generations, advanced osteoarthritis of the knee is a common condition in modern society.  Seniors who typically have a knee replaced are in poor physical shape due to inactivity; have poor muscle tone or bone mass; and are often overweight, which leads to long recovery and rehabilitation.  Boomers generally are in better physical shape and are having knee replacements at a younger age in order to return to their activities.

Cold laser therapy is a modality that is used to help reduce pain and inflammation; speed tissue healing by increasing vasodilation to bring in oxygen and nutrients and most importantly increasing ATP production, the cell’s energy source, to promote collagen formation.  Cold laser is safe to use on orthopedic appliances such as pins, plates and replaced joints as it does not heat. Ultrasound is contraindicated as it produces heat and electrotherapy is contraindicated as it conducts. 

Cold laser can be applied almost immediately after surgery as long as the wound is not open and there is no infection.  With surgery, the soft issues have been traumatized and your body is rapidly repairing the damage.  This is a time when there is a high need for cellular energy and nutrients.  The Theralase cold laser can penetrate 2 inches directly and 4 inches indirectly into the soft tissue;  speeding  the healing process by up to 50%, with much stronger collagen and less scar tissue.  This can allow the patient to participate in rehabilitation to strengthen up the muscles and allow an earlier return to activities.