Back Pain: Intervertebral Disc Conditions

The term ‘disc’ is short for the ‘intervertebral discs’, the spongy cushions that separate the block-like bones (vertebrae) of the spine. These discs have a number of important functions including shock absorption, keeping the vertebral column stable and giving the vertebrae ‘pivot points’ to allow movement. 

A disc is made of two parts: the elastic outer shell (annulus fibrosis) and the jelly-like contents (nucleus pulposis). It can handle quite a lot of pressure without damage, but certain types of pressure can damage the shell and push its contents out. 

Symptoms of disc problems

The symptoms of a damaged disc can vary according to its location and severity. Many people who show evidence on scanning of damaged discs have no symptoms. This means that, most commonly, there are no symptoms at all. However, general signs may include:

• Back pain
• Pain radiating down the legs
• Worsening pain associated with bending over or sitting down for a long time
• Worsening pain associated with activities like coughing or sneezing
• Numbness or pins-and-needles in an arm or leg.

Risk factors for disc problems

Some people are more susceptible to disc problems than others. Risk factors include:

• Obesity
• Poor muscle tone
• Lack of regular exercise
• Cigarette smoking
• Advancing age
• Poor posture
• Incorrect lifting techniques.

Often, however, there is no recognisable risk factor present.

Types of disc problems

Common disc-related problems include degenerative disc disease, ruptured (or ‘slipped’) disc and sciatica (nerve pain).

Degenerative disc disease

The discs of a young child are plump and moist, but the water content reduces with age until the discs are comparatively thin and hard. As a result of this, friction between the bones is thought to increase, resulting in growths called bone spurs around the discs.

In many cases, these age-related changes cause no problems, but some people experience a painful condition called degenerative disc disease. The most common symptom is back pain caused by holding the same position (either sitting or standing) for too long. It’s among the most common causes of chronic back pain in older people. 

Ruptured disc

The term ‘slipped disc’ suggests that a disc has moved out of position, but this is not accurate. The discs are held firmly in place by various structures (including ligaments, muscles and the vertebrae themselves).

Terms like ‘ruptured’, ‘herniated’ or ‘prolapsed’ describe the situation better, as the real problem is not that the entire disc ‘slips’, but rather that a crack in the tough outer shell of the disc allows the soft jelly-like contents to ooze out. When this material comes into contact with other structures, especially the spinal nerves that run nearby, this can cause pain and alter nerve function. 

The most common site for a ruptured disc is the lower back, and chronic lower backache can be a symptom. As we get older, the risk of rupturing a disc declines because the discs dry out and the contents are less able to ooze through any cracks.

Sciatica

Sciatica is nerve pain from the sciatic nerve that runs from the spine into the buttock and down the back of the leg. A common cause of sciatica is a ruptured disc. The spinal cord normally has room to slide up and down inside the spinal column whenever the body moves. However, a bulging disc can protrude into the spinal column and press against the spinal nerves, hampering its movement and causing pain. 

Diagnosis of disc problems

Diagnosis of disc problems involves:

• Taking a medical history (to determine risk factors and predisposing conditions)
• A physical examination.

Other investigations are carried out if surgery may be required.

Treatment for disc problems

The majority of disc problems will resolve regardless of treatment. Bed rest is occasionally best for initial management of severe sciatica, but most people can keep active with some restrictions according to the level of pain. Good pain control and allowing the person to move is often a good approach. 

Some common treatments include:

• Heat treatment
• Regular massage
• An exercise program designed to improve strength and flexibility
• Non-steroidal anti-inflammatory drugs (NSAIDs) or steroids
• Pain-relieving medication
• An injection of anti-inflammatory steroids into the region of the disc
• Uncommonly, in severe cases of ruptured disc, an operation may be needed to trim the protruding bulge (laminectomy)
• Also uncommonly, in severe cases of degenerative disc disease, an operation may be needed to remove the disc and fuse together the two vertebrae on either side.

Remember, most disc problems resolve without specific treatment. 

Self-help for disc problems

Given time and the right conditions, a ruptured disc can heal itself. Ongoing maintenance can reduce the risk of disc problems in the future. Be guided by your doctor or health professional, but general suggestions include:

• Try not to sit still for long periods of time.
• Avoid lifting heavy objects.
• Remember that movements such as bending and twisting (especially at the same time) can increase pressure on your damaged disc.
• Work on increasing your abdominal strength. Strong stomach muscles help to support the back. People who work hard on their abdominal muscles probably have much less recurrence of back pain over the long term, but only if they keep doing the exercises.
• Pay attention to posture while sitting, standing and walking.
• Flexibility exercises, performed regularly, can improve mobility and help reduce muscle tension and back pain.
• Include a gentle program of back-strengthening exercises.
• Yoga is recommended by some practitioners as an excellent form of strengthening and stretching for people with back problems.

Other causes of back pain

There are many other causes of back pain, so see your doctor if pain is strong. Important other reasons for back pain include:

• Muscular pain – probably even more common than disc rupture. It is usually localised to the back, without the pain spreading to the legs and very likely to fix itself without specific treatment
• Fracture – especially in elderly people, or those with osteoporosis
• Malignancy – some cancers can present with back pain. See your doctor if you have strong pain, night pain, have experienced weight loss or any other symptoms you are worried about.

Where to get help

• Your doctor
• Physiotherapist
• Osteopath

Things to remember

• Intervertebral discs are spongy cushions found between the vertebrae of the spine.
• Common problems include degenerative disc disease and ruptured (or ‘slipped’) disc.
• Risk factors for disc problems include obesity, advancing age, lack of exercise and incorrect lifting techniques.

This article originally appeared on www.betterhealth.vic.gov.au

It’s Official: Acupuncture Doctor Approved

The American College of Physicians formally recommends acupuncture for the treatment of back pain. Published in the prestigious Annals of Internal Medicine, clinical guidelines were developed by the American College of Physicians (ACP) to present recommendations based on evidence. Citing quality evidence in modern research, the ACP notes that nonpharmacologic treatment with acupuncture for the treatment of chronic low back pain is recommended. The official grade by the ACP is a “strong recommendation.” [1]

A major goal of the recommendation is for acupuncture and other nonpharmacological therapies to replace drug therapy as a primary source of pain relief. Treatment with opioids is only recommended, with an official “weak recommendation,” when other modalities do not provide adequate relief. A strong recommendation is also made by the American College of Physicians for the treatment of both acute and subacute lower back pain with heat, massage, acupuncture, and spinal manipulation. [2] The recommendations were approved by the ACP Board of Regents and involves evidence based recommendations from doctors at the Penn Health System (Philadelphia, Pennsylvania), Minneapolis Veterans Affairs Medical Center (Minnesota), and the Yale School of Medicine (New Haven, Connecticut). 

The American College of Physicians notes that approximately 25% of USA adults have had, at the very minimum, a one day lower back pain episode within the past three months. The socioeconomic impact of lower back pain in the USA was approximately $100 billion in the year 2006 . The costs include medical care and indirect costs due to lost wages and declines in productivity. [3] Recommendations for treatment options, including those for the use of acupuncture, include considerations of positive medical patient outcomes, the total number of back pain episodes, duration between episodes, alleviation of lower back pain, improvement in function of the back, and work disability reductions. Recommendations are for both radicular and nonradicular lower back pain.

The target audience for the American College of Physicians recommendations includes all doctors, other clinicians, and the adult population with lower back pain. The ACP notes, “Moderate-quality evidence showed that acupuncture was associated with moderately lower pain intensity and improved function compared with no acupuncture at the end of treatment .” [4] In agreement, the National Institute of Neurological Disorders and Stroke (National Institutes of Health) notes that acupuncture is an effective treatment modality for the relief of chronic lower back pain. [5]

These findings are consistent with those published in Mayo Clinic proceedings finding that acupuncture is effective for the treatment of lower back pain. The same Mayo Clinic report notes that acupuncture does not cause any significant adverse effects. [6] The Mayo Clinic findings apply to both nociceptive and non-nociceptive pain. Nociceptive back pain includes musculoskeletal inflammation and pain involving nerve cells wherein nociceptors are activated. Nociceptors are afferent neurons in the skin, muscles, joints, and other areas. For example, nerve impingement (often referred to as a “pinched nerve”) produces one type of nociceptive pain.

Non-nociceptive pain does not involve inflammation and is more relevant to pain processing in the central nervous system. One type of non-nociceptive pain condition is fibromyalgia and acupuncture has been confirmed as an effective treatment modality for this condition. The Mayo Clinic proceedings note, “Martin et al. found a significant improvement between electroacupuncture vs sham electroacupuncture. Differences were seen on the Fibromyalgia Impact Questionnaire (FIQ) scores for fatigue and anxiety.” [7]

Learn more about how to alleviate fibromyalgia related pain in the acupuncture continuing education course entitled Fibromyalgia Syndrome Treatments. Click the following to learn more:

Fibromyalgia Online Course >
 

The Mayo Clinic and American College of Physicians findings are consistent with additional quality research. Memorial Sloan Kettering Cancer Center (New York) and University of York (United Kingdom) researchers note “We have provided the most robust evidence from high-quality trials on acupuncture for chronic pain. The synthesis of high-quality IPD found that acupuncture was more effective than both usual care and sham acupuncture. Acupuncture is one of the more clinically effective physical therapies for osteoarthritis and is also cost-effective if only high-quality trials are analysed.” [8]

Doctors understand the true need for effective pain management. Nonpharmacological solutions are important for a variety of reasons including prevention of addiction, effective relief of pain, and prevention of adverse effects. This is often of heightened concern during pregnancy and for children. As a result, university hospitals integrate acupuncture into usual care settings to improve patient outcomes. For example, pediatric doctors at the UCSF Benioff Children’s Hospital San Francisco provide acupuncture to children, including non-needle laser acupuncture. At the University of California hospital, acupuncture is made available for both inpatients and outpatients. Dr. Kim notes that acupuncture reduces nausea up to 70%. She adds that acupuncture is also effective for significant reductions in post-surgical pain and chronic headaches. [9]

Recently, researchers have discovered how acupuncture stops pain and provides other forms of relief for patients. Breakthrough research conducted by University of South Florida (Tampa) and Fujian University of Traditional Chinese Medicine (Fuzhou) researchers documents how acupuncture stops pain. The researchers note, “acupuncture exerts a remarkable analgesic effect on SCI [spinal cord injury] by also inhibiting production of microglial cells through attenuation of p38MAPK and ERK activation.” [10]

Microglia are central nervous system immunity cells that secrete proinflammatory and neurotoxic mediators. Acupuncture reduces pain by attenuating this response. The researchers also document that acupuncture provides neuroprotection. The researchers note that acupuncture prevents brain damage in the hippocampus by “preventing microglial activation.” The University of South Florida members of the research team were from the Department of Neurosurgery and Brain Repair and the Department of Pharmaceutical Sciences. Funding was provided by the United States Department of Defense, University of South Florida Neurosurgery and Brain Repair, and the James and Esther King Biomedical Research Foundation.

The aforementioned research reveals an important biochemical mechanism involved in acupuncture’s ability to alleviate pain and reduce harmful inflammation. Researchers focus on other mechanisms activated by administration of acupuncture treatments. For example, laboratory investigations reveal how acupuncture regulates blood pressure.

University of California (Irvine) researchers find acupuncture effective for the treatment of high blood pressure. In a controlled laboratory study, University of California researchers have proven that electroacupuncture at acupoint ST36 (Zusanli) promotes enkephalin production, which dampens proinflammatory excitatory responses from the sympathetic nervous system that cause hypertension. Specifically, electroacupuncture regulates preproenkephalin gene expression, a precursor substance that encodes proenkephalin, which then stimulates the production of enkephalin. [11]

The formal recommendation for the use of acupuncture in cases of lower back pain by the American College of Physicians is based on modern research. Mayo Clinic findings and research from the Memorial Sloan Kettering Cancer Center (New York) and the University of York support this recommendation. In response to the needs of patients, doctors have already implemented acupuncture into several hospitals throughout the USA and both inpatient and outpatient acupuncture treatments are available.

Now, modern scientific investigations reveal how acupuncture works. University of South Florida and Fujian University of Traditional Chinese Medicine researchers confirm acupuncture’s ability to attenuate microglial activation. University of California researchers have quantified acupuncture’s ability to control inflammation by regulating enkephalins. In addition, the NCCAOM (National Certification Commission for Acupuncture and Oriental Medicine) provides professional certification for acupuncturists, which ensures standards of excellence for licensed acupuncturists. Given the large body of supportive research and the administrative support for providing safe and effective acupuncture to the general public, expect to see greater implementation of acupuncture into usual care settings.

Accessibility to care is dependent upon both availability and financial capabilities. Insurance companies have been providing health insurance coverage for acupuncture for decades. Cigna, Blue Cross, Blue Shield, AETNA, United Healthcare, and many other insurance companies provide reimbursement to patients for use of services by licensed acupuncturists. The level of coverage varies, largely dependent upon individual health insurance policy provisions. Licensed acupuncturists can learn more about providing coverage for their patients in the continuing education course entitled Acupuncture Insurance Billing #1. This basic introductory course covers diagnostic requirements, including ICD-10 coding, and other important procedural requirements necessary to obtain reimbursements for patient care.
 

References
1. Qaseem, Amir, Timothy J. Wilt, Robert M. McLean, and Mary Ann Forciea. "Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of PhysiciansNoninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain." Annals of Internal Medicine (2017).
2. Qaseem, et al. Annals of Internal Medicine (2017).

3. Katz J.N. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences.J Bone Joint Surg Am200688 Suppl 2214.
4. Lam M. Galvin R. Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis.Spine (Philadelphia, Pennsylvania 1976) 201338212438.
5. ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Low-Back-Pain-Fact-Sheet. Low Back Pain Fact Sheet, National Institute of Neurological Disorders and Stroke, National Institutes of Health.
6. Nahin, Richard L., Robin Boineau, Partap S. Khalsa, Barbara J. Stussman, and Wendy J. Weber. "Evidence-based evaluation of complementary health approaches for pain management in the United States." In Mayo Clinic Proceedings, vol. 91, no. 9, pp. 1292-1306. Elsevier, 2016.
7. Martin DP, Sletten CD, Williams BA, Berger IH. Improvement
in fibromyalgia symptoms with acupuncture: results of a randomized
controlled trial. Mayo Clin Proc. 2006;81(6):749-757.
8. MacPherson, H., A. Vickers, M. Bland, D. Torgerson, M. Corbett, E. Spackman, P. Saramago et al. "Acupuncture for chronic pain and depression in primary care: a programme of research." (2017).

9. Leslie Lingaas. ucsf.edu/news/2014/04/113966/acupuncture-helps-young-patients-manage-pain. Acupuncture Helps Pediatric Patients Manage Pain and Nausea, 2014.
10. Lin, Lili, Nikola Skakavac, Xiaoyang Lin, Dong Lin, Mia C. Borlongan, Cesar V. Borlongan, and Chuanhai Cao. "Acupuncture-induced analgesia: the role of microglial inhibition." Cell transplantation 25, no. 4 (2016): 621-628.
11. Cevic, C and Iseri, SO. The effect of acupuncture on high blood pressure of patients using antihypertensive drugs. Acupuncture & electro-therapeutics research 2013; 38(1-2): 1-15. ncbi.nlm.nih.gov/pubmed/23724695.

This article originally appeared on http://www.healthcmi.com

What Does a Osteopathic Manual Therapist Do?

Soft Tissue Manipulation

The practitioner uses soft tissue manipulation in many different ways. In general, they use it to evaluate the condition of tissues and to help the body’s fluids (such as blood and lymphatic fluid) flow smoothly. Keeping fluids flowing smoothly reduces harmful fluid retention and makes the body’s immune system more effective. Fascia is tissue found in all parts of the body. It connects all of the body’s structures at both superficial and deep levels. Practitioners evaluate the fascia to find areas of restriction, and then use soft tissue manipulation to make sure the length and tension of the fascia are properly balanced. Throughout the treatment, manual osteopaths keep checking on the state of the body’s tissues. If one technique isn’t working to correct a restriction, they use another approach instead. Above all, manual osteopaths try to restore health without over-treating.

Osteopathic Articular Technique

Osteopathic Manual Therapists use this technique to reduce muscle spasms near a joint, ease neurological irritations around a joint, make joints more mobile and to reduce pain and discomfort.  The articular technique involves gently moving 2 joint surfaces.  Before doing this, manual osteopaths carefully prepare the soft tissues around the treatment area.  They also move the patient into a position that will minimize, or eliminate the energy and force needed to perform the manoever.  Many patients find this technique less forceful than joint manipulations.

Cranial Osteopathic Manual Therapy

This is a very gentle osteopathic technique, and it requires the most experience to use effectively. To learn this technique, Manual osteopaths undergo intensive training. Through this training, their hands become sensitive to the cranial mobility and develop great precision in utilizing cranial techniques. Manual osteopaths use this gentle technique to assess and treat the mobility of the skull and its contents. They may also use it to assess and treat the spine, the sacrum, and other parts of the body. The goal of this technique is to adjust the body’s physiology by restoring balance to the circulation of the blood and other body fluids. Manual osteopaths do this by treating the body’s inherent biorhythm. They are able to feel this rhythm in the patient’s head, spinal cord, and in the sacrum and the rest of the body. Manual osteopaths use the biorhythm to assess the patient’s condition, and they may modify it during treatment.

Visceral Manipulation

Osteopathic Manual Therapists use visceral manipulation to treat organs and viscera of the body, including the lungs, heart, liver, spleen, kidneys, stomach, pancreas, intestines, bladder and uterus. Patients may feel pain in one or more of these organs, or the viscera may be less pliable than it should be. Manual osteopaths gently move the structures themselves and the fascia (connective tissue) that surrounds them to restore full movement.

Most patients treated with visceral manipulation feel only the gentle pressure of the manual osteopath’s hand, but the corrections are powerful enough to improve the mobility of an organ, improve blood flow, and help the organ function more effectively.

The above (and many other) osteopathic manual techniques and approaches are used in a coordinated and rational fashion to slowly adjust the patients anatomy and physiology towards normal, so that the patient’s body can heal itself.

This article originally appeared on nmoc.ca

 

5 Reasons You Should Try Acupuncture Right Now

In the West, acupuncture is still sometimes dismissed — even as more western doctors are incorporating the practice into their treatment plans. Nonetheless, acupuncture is becoming increasingly recognized as an effective treatment for relieving pain, easing stress and even combating insomnia. And in the right hands, acupuncture can also be used to treat a wide array of other symptoms and disorders — as it has been in China and many other countries for centuries.

There is nothing magical or superstitious about it. A doctor's office in Shanghai or Hong Kong is not so different from what you'd find in the United States. What is different however, is that acupuncture is a highly respected and frequently used modality for a range of health and medical conditions.

As practitioners and patients in Asia know quite well, the benefits of acupuncture extend much farther, into areas that might even surprise you. Here are five reasons why acupuncture could soon go mainstream as a form of treatment:

1. Allergies

While Western medicine focuses on treating the uncomfortable symptoms of allergies, Traditional Chinese Medicine — using a combination of acupuncture and herbal treatments — treats the whole person from the inside out. This approach works not only to treat the acute symptoms felt during an allergic reaction, but to regulate the immune system. A healthy functioning immune system will improve an individual's health overall, and reduce the severity and frequency of symptoms.

2. Weight Loss

The inability to achieve a healthy weight can be one of the most stubborn problems patients face, and part of the problem lies in the hypothalamus — the part of the brain that regulates hunger, among other things. Acupuncture can be used to stimulate the hypothalamus, quieting its hunger signals and normalizing appetite. And because acupuncture also relieves stress, it inhibits "stress-eating" and rids the body of fat-storing stress hormones like cortisol.

3. Chemotherapy Side-Effects

Chemotherapy uses drugs to inhibit the growth of cancer cells, a critically important action in fighting cancer. But its side effects — nausea, sore joints, dry mouth, hot flashes and fatigue — are tough on the patient. Acupuncture and electro-acupuncture work to activate chemicals in the brain that block pain. This creates relaxing, pleasurable sensations that can provide much-needed relief for patientsundergoing treatment. Patients can also choose acupressure and cold laser acupuncture, which achieve similar results without the use of needles.

4. Infertility

When the body's physiological systems are impaired by stress, or when neurological connectivity is unbalanced and hormones are being triggered in unhealthy ways, infertility can result. Frustratingly, modern fertility treatments are often hampered by these underlying issues. Acupuncture works to help reset neurological circuits. This can reduce hormonal imbalances and overall stress, and boosts the efficacy of fertility treatments.

5. Smoking Cessation

Nicotine is highly addictive, and the symptoms provoked by quitting smoking include intense cravings, irritability, anxiety, poor sleep, headache, increased appetite, fatigue and difficulty concentrating.

Western aids like the nicotine patch merely delay the onset of symptoms. True relief and success in quitting are possible through the use of acupuncture, which can reduce cravings and alleviate withdrawal symptoms. When you add stress relief to the process, quitting smoking can become easier and totally possible. A qualified practitioner will also provide personalized exercise and dietary recommendations, herbal supplements and an analysis of your triggers for smoking and how to avoid them.

Acupuncture has countless applications for patient health. When combined with other modalities from Traditional Chinese Medicine, or in an integrated fashion with western medicine, the results can be highly effective. This ancient discipline treats the whole person, restoring balance, strengthening immunity and helping physiological systems thrive.

This article originally appeared on mindbodygreen.com and was written by Dr. Daniel Hsu