How long will I need to come for treatment?

Frequency and duration of care are issues which the chiropractic profession has established formal guidelines in Canada since 1993.  This evidence based practice covers three areas: acute, uncomplicated pain; acute, complicated or chronic pain; and supportive or maintenance care.

Acute, uncomplicated pain applies to patients with pain of less than 3 weeks duration and with a common diagnosis of mechanical back pain (strain/dysfunction).  The protocol for these patients is to provide up to 3 treatments per week for 4 weeks.  If there is no improvement after 2 weeks, treatment should be modified.  If there is no improvement by 4 weeks or symptoms are progressive, treatment should stop and the patient be referred out to another health professional.  Typically, if the patient is showing improvement, there is an encouragement to return to modified activities and an exercise component is introduced with a decrease in visit frequency (e.g. to weekly) for another 4 weeks, for a total time of 8 weeks.  When maximum medical recovery is reached, the patient may either be discharged or maintenance care may be recommended.

Acute, complicated or chronic pain applies to patients with complications (significant trauma,   significant underlying spinal degeneration, a disc problem with neurological referral, etc) or chronic pain (recurrent, disabling attacks of spinal pain or pain for 12 weeks or more duration).  Treatment may be slightly more frequent (e.g. 3 times a week for 4-6 weeks, than 2 times a week for another 4-6 weeks) and for a longer duration (e.g. up to a total of 16 weeks).  Patients would be typically reassessed every 2-4 weeks to determine if there is improvement in symptoms and function, and whether to continue treatment or to refer to another health professional.  Advice on return to modified activities and specific exercise would be accompanied with a discussion on pain behavior.  If the patient has not returned to pre-episode status, a period of treatment withdrawal may determine if they have reached maximum medical recovery and whether they should be discharged or recommendations of supportive  care be given.  If maximum medical recovery has been reached, either discharge or maintenance care may be recommended.

Guidelines define two different forms of longer term chiropractic treatment.  Supportive care is for patients who have reached maximum improvement, but fail to sustain this improvement and who progressively deteriorate when treatment is withdrawn.  This treatment is determined to be therapeutically necessary, but must be determined on an individual basis.  Maintenance or preventative care is treatment for a patient who has no present symptoms but may seek to prevent recurrent episodes of back pain and promote health.  Typically, chiropractors have recommended monthly maintenance care.

Laser Therapy for Chronic Achilles Tendinopathy

Achilles Tendinopathy is common in many athletes following injury, and can lead to tendon degeneration, pain, loss of performance and eventual tendon rupture.  A study published in the American Journal of Sports Medicine investigated whether the addition of low level laser therapy (LLLT) for 8 weeks in addition to an eccentric exercise (EE) program would speed recovery and improve outcomes in recreational athletes with chronic Achilles Tendinopathy.

52 athletes with symptoms of at least 6 months of unilateral, activity limiting pain in the Achilles tendon were included.  They were randomized into two groups, the first group having EE and LLLT and the second group having EE with placebo LLLT.  LLLT and placebo LLLT were administered twice a week for 4 weeks, than weekly for 4 weeks.  EE were performed 4 times a week, consisting of unilateral calf raises performed on a step which started with body weight only, and progressed with weight in a back pack, beginning with 1 set of 15 reps and progressing to 12 sets of 12 reps.  Static stretching of the Achilles tendon was included.

 Outcomes were measured at 4, 8 and 12 weeks.  Pain intensity during physical activity was significantly better in the true LLLT group at every stage of assessment, and all secondary outcomes were also significantly better.  This study provides evidence that adding LLLT to an EE program may speed recovery and improve outcomes, up to 4 weeks following treatment.

Citation: American Journal of Sports Medicine 2008; 36(5):881-887.

Spinal Manipulation for Chronic Cervicogenic Headaches

Headache symptoms are very common, effecting approximately 16% of the population, and can be divided into three main categories:  migraine, tension and cervicogenic headaches.  Cervicogenic headaches are associated with neck pain and mechanical dysfunction of the cervical spine and therefore in theory should respond to spinal manipulation therapy (SMT) to restore normal neck movement. 

A 2010 pilot study looked at patients with chronic cervicogenic headaches.  The criteria included: at least 5 headaches a month for over 3 months; pain which started at the base of the skull and radiated over the top of the head to the front: and pain/reduced range of motion in the cervical spine.  The patients were randomly assigned to 4 treatment groups for the 8 week study:

·         High dose SMT (manipulation twice a week, totally 16 treatments)

·          Low dose SMT (manipulation once a week, with the second session per week for information only, totally 8 treatments)

·          High dose light massage (twice a week treatments, totally 16 treatments)

·         Low dose light massage (weekly treatments with a second session per week for information only, totally 8 treatments)

The results of the study were:

• There was no difference in the high or low dose SMT groups, but SMT was more effective than light massage.  At 8 weeks, the number of weekly headaches had decreased by 50% in the patients who received SMT.
• This difference was both statistically and clinically significant.  Overall there was a decrease in intensity/pain of the cervicogenic headaches, decrease in headache frequency; and decrease in medication intake which was sustained with the SMT groups.

This study supports that SMT can work as an additional intervention with cervicogenic headaches, best  in combination with soft tissue treatment, exercise and education.

Citation:  The Spine Journal 2010; 10:117-128

Maintenance Care for Chronic Low Back Pain

A landmark study which was accepted in January, 2011 to be published in Spine looked at maintenance spinal manipulation therapy (SMT) for chronic, non specific low back pain (LBP) and whether there was a reduction of pain and disability levels over an extended period of time.  About 85 % of LBP patients who seek treatment are of a non specific variety, where there is a lack of underlying pathology (bone or nerve).  LBP is considered chronic when it has been present for over 12 weeks. 

The study was divided into three groups:  control (sham manipulation), SMT for one month, SMT for 10 months.  Treatment was given three times a week for the first month of the study, with patients in both the SMT groups reporting significantly lower pain and disability than the control group.  Following the second phase of treatment (10 months), patients who received bi weekly maintenance SMT had significantly lower pain and disability scores than those patients who did not have maintenance SMT.  Although the outcome measures for both the SMT groups were similar after one month, the non maintenance SMT group gradually returned to pre treatment levels (similar to the control group) by the end of 10 months. 

Not only did the maintenance SMT group who received care over 10 months have better results regarding their pain and disability levels than those patients who stopped care after one month, they also had improved lumbar mobility and better perceptions of general health.  This study supports what chiropractors have been saying to their patients for years.  Once the initial phase of treatment has been completed to stabilize your back condition, it is beneficial to consider monthly maintenance care to keep your spine functional and hopefully avoid acute episodes of back pain.

Lowering Cholesterol and Triglycerides with Supplements

 Elevated cholesterol and/or triglyceride problems are very common in modern society, and are known to increase risk for heart attack and stroke.  Dietary changes which reduce high fat animal products and consuming food high in fiber are beneficial, but many people are prescribed statins to further reduce their levels of cholesterol and triglycerides.  Unfortunately, these medications have side effects such as muscular pain and liver damage. 

There are two natural agents that have proven cholesterol and triglyceride lowering effects that can be used to complement dietary changes and can be taken safely in conjunction with statin drugs.  Gum Guggul is a resin from a tree native to India that has received prescription status in India in 1986 due to its high level of efficacy in human clinical trials in lowering cholesterol and triglycerides.  Human studies have demonstrated that guggulsterone, the active ingredient in gum guggal, can produce a cholesterol reduction of 14-27 % in 4-12 weeks, and a drop of 22-30 % of triglyceride levels.  A striking feature is its lack of toxicity and side effects, unlike cholesterol lowering drugs. 

Artichoke Leaf Extract is known to increase bile secretion by the liver, which clears more LDL cholesterol from the blood stream as cholesterol is the building block of bile acids.  In a double blind, placebo controlled study of 143 people with high cholesterol, artichoke leaf extract reduced cholesterol by 18.5% as compared to 8.6% in the placebo group, and LDL cholesterol dropped by 23% as compared to 6% to the placebo group; and LDL to HDL ratios declined by 20% vs. 7%. 

To be effective, Gum guggul must be standardized to 50-75 mg of guggulsterone per day, and artichoke leaf extract a minimum of 400 mg taken two to three times daily.  As with all supplements, results may vary, but there is a concrete way to determine if this is supplement is effective.  Have your cholesterol tested and then do a three month trial of Adeeva’s CholesterolEx or similar product and have a follow up cholesterol test.  

Laser Therapy in the Management of Neck Pain

Medical researcher Dr. Roberta Chow, MD, PhD was the lead author of a paper which summarized 16 clinical trials on Low Level Laser Therapy (LLLT) and the management of neck pain.  All the studies used LLLT of varying frequencies, and were double blinded, with either a placebo or control group.  A total of 820 patients were included in the research, which included both acute and chronic neck pain.    

Two trials showed an improvement in acute neck pain with the LLLT group over the placebo group.  Five trials showed an improvement in chronic neck pain with LLLT over the control group.  Eleven trials had a reduction of pain intensity that was statistically significant.  Seven trials involved follow up to 22 weeks after the treatment trial. 

There were mild side effects with LLLT group, but this was no different than with the placebo group. As with any therapy, individual results may vary, but overall the trials showed immediate pain reduction in the acute neck pain patients, and up to 22 weeks of reduced pain in the chronic patients post LLLT treatment.

Citation:  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61522-1/fulltext#article-upsell

What a Pain in the Foot!

Summer time is upon us, and so often shoes are exchanged for flip flops.  The problem with flip flops is that they offer little support, and if you have abnormal foot mechanics such as flat feet, you can develop a painful arch, a condition called plantar fasciitis.   

 Plantar Fasciitis is caused by the breakdown and inflammation of collagen fibers in the thick band on the bottom of the foot that maintains the arch.  The pain can develop gradually over time with the most common symptom being pain in the morning or after prolonged sitting, as the band has shortened but limbers up after a few steps. Xrays may identify a heel spur, which is caused by the prolonged pulling of the plantar fascia from the heel. Secondary complications can develop as the difficulty in walking produces abnormal mechanics causing stress to knees, hips and the lower back.

Risk factors in developing plantar fasciitis include:

·         Increasing age as the ligaments are less supportive

·         Flat feet or high arches which causes faulty foot mechanics

·         Runners or ballet dancers who put abnormal stresses on the feet

·         Obesity and pregnancy places increased weight on the feet

·         Occupations which require prolonged standing

·         Improper shoes which lack arch support

Treatment includes:

·         Rest from activities that require being on the feet

·         Ice and oral anti-inflammatory (Aleve) or creams (Voltaren)

·         Laser, acupuncture or other modalities to increase healing

·         Massage therapy to relax and stretch the fascia and increase blood flow

·         Manipulation of a rigid mid foot to return normal function

·         Orthotics to support the arch and distribute weight for better mechanics

·         Exercises to stretch and strengthen the plantar fascia

·         Taping the arch to maintain support

·         Advice to avoid going barefoot, wear supportive shoes, and maintain a healthy weight

·         Severe cases may require steroid injections when unresponsive to conservative treatments but caution should be used as steroids weaken the collagen fibers

Often there is a combination of treatment that is required to be successful at keeping plantar fasciitis under control.  While individual results may vary, I have had success with laser treatments (approximately five), soft tissue stripping of the fascia of the arch, manipulation of the mid foot, and fittings with orthotics.  Home advice of using a 500 ml ice water bottle to offer both inflammation control and massage, as well as doing stretches also complement the therapy. 

So if you are finding you still want to wear your fancy summer shoes, take care of your feet so you don't develop that chronic pain in the foot!

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