Making The Case for Primary Spine Practitioner Care

Better Option to Back Surgery

“The American Association of Medical Colleges has identified musculoskeletal medicine as an area in which students receive inadequate preparation for practice in the real world.[1] North American medical schools have limited time devoted to musculoskeletal education. Only 30% to 40% of schools have required instruction in the musculoskeletal system.[2][3] Graduates entering practice experience the effects of this lack of instruction; one survey found that half of family physicians reported inadequate musculoskeletal training for clinical practice.[4]”[5]

These are not the words of an opinionated and/or biased chiropractor but those of clinical researchers at the University of Rochester School of Medicine and Dentistry. They admit that as of November 2014,[5] most primary care physicians graduating from medical school lack the confidence to assess and treat musculoskeletal complaints. This fact alone creates a substantial argument for the necessity of an integrative system of healthcare delivery that incorporates Primary Spine Practitioner (PSP) trained providers who possess the knowledge, skill, and ability to triage[6] patients with musculoskeletal complaints.

PSP trained providers [DC, PT, MD, NP, PA] can evaluate and manage the majority of patients with musculoskeletal conditions based upon best available evidence, and in a patient centered model of care. This portal of entry into the healthcare delivery system can then streamline the referral process for those patients who need a level of care beyond that of standard musculoskeletal treatment. Incorporating this type of provider would alleviate the burden of musculoskeletal complaints from primary care practices allowing medical doctors to focus on infectious disease and serious pathology, conditions they ARE TRAINED FOR.  

The desire for this integration became evident to us upon receiving a letter from Excellus Blue Cross/Blue Shield of Rochester dated 29 December 2014. In this letter they outlined a “Waived Copayment Pilot Program” whose purpose is to “help drive care to spine pathway trained practitioners so that the program’s value can be measured and compared to other modalities of treatment for back and neck pain”. This program will extend until 31 December 2015 and only include Excellus employees and their covered family members but underlines the fact that a major health insurer believes PSPs are credible portal of entry providers for patients who present with musculoskeletal conditions.

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[1] Association of American Medical Colleges. Medical School Objectives Project. Contemporary issues in medicine: musculoskeletal medicine education. Report VII. 2005.

[2] DiCaprio MR, Covey A, Bernstein J. Curricular requirements for musculoskeletal medicine in American medical schools. J Bone Joint Surg Am. 2003 Mar;85(3):565-7.FREE Full Text

[3] Pinney SJ, Regan WD. Educating medical students about musculoskeletal problems. Are community needs reflected in the curricula of Canadian medical schools? J Bone Joint Surg Am. 2001 Sep;83(9):1317-20.Abstract/FREE Full Text

[4] Sneiderman C. Orthopedic practice and training of family physicians: a survey of 302 North Carolina practitioners. J Fam Pract. 1977 Feb;4(2):267-50.Medline

[5] DiGiovann, Benedict F., , MD, Richard D. Southgate, , MD, Christopher J. Mooney, , MA, MPH, Jennifer Y. Chu, , MD, David R. Lambert, , MD, and Regis J. O’Keefe, , MD, PhD. "Factors Impacting Musculoskeletal Knowledge and Clinical Confidence in Graduating Medical Students."The Journal of Bone and Joint Surgery E185 96.21 (2014): n. pag. The Journal of Bone and Joint Surgery, Inc. The Journal of Bone and Joint Surgery, Inc.; STRIATUS Orthopaedic Communications, 05 Nov. 2014. Web. 17 Jan. 2015. <http://jbjs.org/content/96/21/e185>. 

Investigation performed at the Department of Orthopaedics and Rehabilitation, University of Rochester School of Medicine and Dentistry, Rochester, New York

[6] Process of organizing several patients for treatment. The process of deciding which people in a hospital department should get medical treatment first, according to how serious their condition is..

Link to the full article:

https://plus.google.com/114651765255995665833/posts/4PEFAr1kaDQ

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WHAT YOU NEED TO KNOW ABOUT SCIATICA

Taken from our 25 July 14 Spine-Health Powered Newsletter

The term sciatica describes the symptoms of leg pain and possibly tingling, numbness or weakness that originates in the lower back and travels through the buttock and down the large sciatic nerve in the back of the leg.  Sciatica (pronounced sigh‐at‐ih‐kah) is not a medical diagnosis in and of itself ‐ it is a symptom of an underlying medical condition.

SCIATICA NERVE PAIN

Sciatica is often characterized by one or more of the following symptoms:

• Constant pain in only one side of the buttock or leg (rarely can occur in both legs)

• Pain that is worse when sitting

• Burning or tingling down the leg (vs. a dull ache)

• Weakness, numbness or difficulty moving the leg or foot

• A sharp pain that may make it difficult to stand up or to walk

Sciatica Nerve Inflammation Pattern

Sciatic pain can vary from infrequent and irritating to constant and incapacitating. Specific sciatica symptoms also vary widely in type, location and severity, depending upon the condition causing the sciatica.

While symptoms can be very painful, it is rare that permanent sciatic nerve damage (tissue damage) will result.

THE SCIATIC NERVE AND SCIATICA

The sciatic nerve is the largest single nerve in the body and is composed of individual nerve roots that start by branching out from the spine in the lower back and combine to form the "sciatic nerve." When it is irritated, sciatica symptoms occur.

• The sciatic nerve starts in the lower back at lumbar segment 3 (L3).

• At each level of the lower spine a nerve root exits from the inside of the spine and then comes together to make up the large sciatic nerve.

• The sciatic nerve runs from the lower back, down the back of each leg

• Portions of the sciatic nerve then branch out in each leg to innervate certain parts of the leg [e.g. the buttock, thigh, calf, foot, toes]

The sciatica symptoms (e.g., leg pain, numbness, tingling, weakness, possibly symptoms that radiate into the foot) are different depending on where the nerve is pinched. For example, a lumbar segment 5 (L5) nerve impingement can cause weakness in extension of the big toe and potentially in the ankle.

THE COURSE OF SCIATICA PAIN

The incidence of sciatica increases in middle age. Rarely occurring before age 20, the probability of experiencing sciatic pain peaks in the 50's and then declines.

Often, a particular event or injury does not cause sciatica, but rather it tends to develop over time. The vast majority of people who experience sciatica get better within a few weeks or months and find painrelief with non-surgical sciatica treatment. For others, however, sciatica pain from a pinched nerve can be severe and debilitating.

There are a few symptoms that may require immediate medical, and possibly surgical, intervention, such as progressive neurological symptoms (e.g. leg weakness) and/or bowel or bladder dysfunction (Cauda Equina Syndrome).

Because sciatica is caused by an underlying medical condition, treatment is focused on relieving the underlying causes of symptoms. Treatment is usually self-care and/or non-surgical, but for severe or intractable cases surgery may be an option.

MOST COMMON CAUSES OF SCIATICA

• Lumbar herniated disc (also referred to as a slipped, ruptured, bulging, or protruding disc, or a pinched nerve) occurs when the soft inner core of the disc leaks out through the outer core and irritates the nerve root. Sciatica is the most common symptom of a lumbar herniated disc.

• Degenerative disc disease is diagnosed when a weakened disc results in excessive micro-motion at that spinal level, and inflammatory proteins from inside the disc become exposed and irritate the area (including the nerve roots).

• Isthmic spondylolisthesis. This condition occurs when a small stress fracture allows one vertebral body to slip forward on another (e.g. the L5 vertebra slips over the S1 vertebra). The combination of disc space collapse, the fracture, and the vertebral body slipping forward, can cause the nerve to get pinched and cause sciatica.

• Lumbar spinal stenosis is related to natural aging in the spine and is relatively common in adults over age 60. The condition typically results from a combination of one or more of the following: enlarged facet joints, overgrowth of soft tissue, and a bulging disc placing pressure on the nerve roots, causing sciatica pain.

• Piriformis syndrome. The sciatic nerve can get irritated as it runs under the piriformis muscle in the buttock. If the piriformis muscle irritates or pinches a nerve root that comprises the sciatic nerve, it can cause sciatica- type pain.

• Sacroiliac joint dysfunction. Irritation of the sacroiliac joint - located at the bottom of the spine - can also irritate the L5 nerve, which lies on top of the sacroiliac joint, causing sciatica- type pain.

Click here to read the full article:  http://www.spine-health.com/  conditions/sciatica/what-you-need-know-about-sciatica

HOW A DISC BECOMES PAINFUL

This post was taken from our 18 July 14 Spine-Health Powered Newsletter

Each spinal disc is a unique and well-designed structure in the spine. It is strong enough to resist terrific forces in multiple different planes of motion, yet it is still highly mobile and permits motion in multiple directions.

The disc has several functions, including acting as a shock absorber between the bony vertebral bodies.

DISC ANATOMY AND FUNCTION

The intervertebral disc has been likened to a jelly donut. It is comprised of a series of bands that form a tough outer layer, and soft, jelly-like material contained within.

    - Annulus Fibrosus - the disc's firm, tough outer layer

Nerves to the disc space only penetrate into the very outer portion of the annulus fibrosus. Even though there is little innervation to the disc, it can become a significant source of back pain if a tear in the annulus reaches the outer portion and the nerves become sensitized.

With continued degeneration, the nerves on the periphery of the disc will actually grow further into the disc space and become a source of pain.

    - Nucleus Pulposus - the jelly-like inner disc material

The inner material contained in the disc, the nucleus pulposus, contains a great deal of inflammatory proteins. If this inner disc material leaks out of the disc and comes in contact with a nerve root, it will inflame the nerve root and create pain down the leg (sciatica or lumbar radiculopathy) or down the arm (cervical radiculopathy).

When we are born, the disc is comprised of about 80% water, which gives it its spongy quality and allows it to function as a shock absorber. As we age, the water content decreases and the disc becomes less capable of acting as a shock absorber

In the same manner, if any of the inflammatory proteins within the disc space leak out to the outer annulus and touch the pain fibers in this area, it can create a lot of low back pain or neck pain. (See Figure 1)

The proteins within the disc space also change composition, and most of us will develop tears into the annulus fibrosus (the outer hard core of the disc).

Most people will have some level of disc degeneration by their sixth decade, yet most do not have back pain (see Figure 2).

Degenerated Disc on MRI Scan

Magnetic Resonance Imaging, called an MRI scan, has contributed a great deal to our understanding of degenerative disc disease and the natural degenerative process. With the advent of MRI technology, good anatomic detail of the disc can be imaged and correlated with the individual's pain.

Through studies with MRI scans, it was found that:

• A large number of young patients with chronic low back pain had evidence of disc degeneration on their MRI scans, and;
• Up to 30% of young healthy adults with no back pain had disc degeneration on their MRI scans.

Variability in Degenerative Disc Disease

It is not exactly clear why some degenerated discs are painful and some are not.

There is probably a variety of reasons that discs can become painful.

Some theories about pain from degenerative disc disease are:

• If a disc is injured or degenerated, it may become painful because of the resultant instability from the disc injury, which in turn can lead to an inflammatory reaction and causes low back pain.
• Some people seem to have nerve endings that penetrate more deeply into the outer annulus than others, and this is thought to make the degenerated disc more susceptible to becoming a source of pain.

 While the exact causes are not known, there is a generally agreed upon theory of how a disc degenerates over time,....... Click here to read the full article: http://www.spine-health.com/conditions/degenerative-disc-disease/how-disc-becomes-painful

CHIROPRACTIC MANIPULATION FOR THE CERVICAL SPINE

This post is taken from our 11 July 14 Spine-Health Powered Newsletter

Manipulation of the cervical spine or neck region is a common technique utilized by doctors of chiropractic for many patients complaining of neck, upper back, and shoulder/arm pain, as well as headaches. Read more about this first line of treatment for cervical spine conditions.

TYPES OF CHIROPRACTIC MANIPULATION

The goals of cervical adjustment include reduction of pain, improved motion, and restored function. There are two general approaches for cervical spine complaints:

- Manipulation - often thought of as the traditional chiropractic adjustment, or a high-velocity, low-amplitude (HVLA) technique

- Mobilization - which is a more gentle/less forceful adjustment, or a low-velocity, low-amplitude (LVLA) technique moving the joint through a tolerable range of motion.

A combination of the various approaches varies among patients depending on the chiropractor's preferred techniques, the patient's comfort and preferences, and the patient's response to the treatment, as well as both past experience and observations made during the course of treatment.

Adjunctive therapies may include massage, therapeutic heat and/or cold application, gentle stretching and strengthening exercises, and more.

THE “CRACKING” SOUND

The HVLA manipulation usually results in a release, called cavitation, which is created in part by gas escaping from the joint capsule when the joint is moved quickly within its passive range of motion, well within the tissue boundaries.

This type of chiropractic adjustment creates the typical cracking sound that is often associated with joint manipulation. It sounds similar to cracking one's knuckles.

While this cracking description of a chiropractic high-velocity, low- amplitude thrust may give an impression of something that is uncomfortable, many patients find the sensation is relieving and may provide immediate relief of painful symptoms.

GENTLE MOBILIZATION OR ADJUSTMENT?

There are several reasons a chiropractor may recommend gentle (LVLA) chiropractic techniques, such as: 

- Patient preference: Some patients do not feel comfortable with the traditional high-velocity thrust manipulation and prefer an approach that does not involve twisting their neck or joint "popping."

- Provider experience: Some chiropractors may favor one technique and most chiropractors utilize several approaches and often modify and adapt several techniques to the patient’s needs and preferences.

- Contraindications: Some patients may not be able to tolerate the traditional chiropractic adjustment based on past experience or a prior injury or condition.

GENTLE TECHNIQUES

If the patient cannot relax, or simply dislikes the cracking feeling or sound, a gentle form of chiropractic adjustment may be utilized. Some of these methods include a slower technique performed within the passive range of joint motion. 

• Cervical mobilization. The chiropractor manually moves the vertebra in the neck left to right, and vice versa, alternating between the side to side motion and a figure 8 movement, applied at varying degrees of moving the head forward, backward, and to the side and in rotation. This is a smooth, non-thrust type of stretch. 

• Cervical manual traction. The chiropractor gently pulls on the neck, stretching the cervical spine often varying the angle between flexion (forward) and extension (backward), based on comfort and searching for the correct angle to most efficiently reduce the tightness. 

• Cervical "drop" techniques. The chiropractor places a hand and/or finger over the spinal segment requiring the adjustment. A medium to high velocity, low amplitude thrust, or a non-thrust gradual increasing downward pressure is applied until the drop section / head piece of the table releases and drops a short distance. The goal is to reduce the fixation or restricted motion of the cervical vertebra assisted by the special table. 

TYPICAL CERVICAL PROBLEMS 

• Mechanical neck pain includes pain generated from muscle, tendons, joint capsules, ligaments and/or the fascia. This type of problem is a common cause of neck pain and stiffness. Most of the time, many of these tissues are simultaneously injured and can cause pain both locally as well as at a distance away from the injury site. 

• Cervical disc problems. Tears can develop in the cervical disc and/or the inside of the disc (the nucleus) can herniate through the outer part (the annulus) and trap or pinch the nerve root as it exits the spine. 

Cervical nerve root irritation can frequently refer pain down the arm and into the hand, usually affecting specific regions such as the 4th and 5th digits, the palm side thumb to 3rd fingers and/or the back of the hand on the thumb, index finger side of the hand, depending on which nerve root is irritated.

The above are two broad examples of types of cervical spine problems that may be treated with cervical spinal manipulation. The patient needs to receive a complete exam prior to cervical manipulation.




Click here to read the full article: http://www.spine-health.com/ treatment/chiropractic/chiropractic- manipulation-cervical-spine

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“Conservative Care First” is more important today than ever in facing our nation’s healthcare challenges

Chiropractic physicians are the highest-rated healthcare practitioners for low-back pain treatments with their patient-centered, whole-person approach that provides greater interaction and communication for appropriate diagnosis and developing more cost-effective treatment planning.

 

October is National Chiropractic Health Month