Chiropractic Treatment of Sciatica

Flexion-distraction therapy is a chiropractic technique that utilizes a multi-function table that enables the chiropractor to combine decompression with other gentle non-force spinal adjustment techniques. Flexion-distraction is well suited for patients who need a lighter touch, such as those recovering from spinal surgery, currently undergoing rehabilitation, or those with osteoporosis or of an advanced age.

Flexion-distraction therapy is well researched and has been proven effective for:

• Reducing pressure on the spinal nerves from a disc bulge or herniation
• Increasing spinal motion within the disc and spinal joints
• Improving posture
• A conservative option to surgery for herniated discs known as discectomy. In fact a 2010 randomized clinical study found that spinal manipulative therapy is just as effective for the treatment of most patients experiencing sciatica secondary to lumbar disc herniation, with 60 percent of sciatica patients able to avoid low back surgery by going to a chiropractor.

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Inversion Tables

I am constantly asked by patients what my professional opinion is regarding inversion tables. In most cases I share my cursory exploration of the subject and advise that they do their homework before buying one. Having been asked this question again only three days ago I felt it only right to review what research literature I could find on the subject so as to provide people with a more detailed point of reference.

My search for credible, unbiased literature revealed a surprisingly scant wealth of resources on the subject. There are plenty of sites with opinion pieces, organizational advocacy, and even consumer testimonials regarding personal experience with inversion (i.e. Spine-Health) but very little medical evidence for or against its use. In fact I could only find two websites where the authors cited medical research to substantiate their advocacy, or lack thereof, for inversion table use in the treatment of musculoskeletal pain.

Edward R. Laskowski, M.D., co-director of the Mayo Clinic Sports Medicine Center and a professor at College of Medicine, Mayo Clinic, published a brief article regarding the subject where he opened his commentary by stating, “Inversion therapy doesn't provide lasting relief from back pain, and it's not safe for everyone”. He went on to describe the effects of inversion and ended by citing its contraindications for use.[1]

Kevin Macpherson, M.Ed., ATC, currently employed by Pivotal Health Solutions, published an article where he cites eight relevant publications and ends his commentary by stating, “If more health-care providers were educated on the benefits of inversion, many patients could receive the lifelong benefits of this therapy and the cost savings to both patients and practitioner can be substantial, as we start to equalize gravity’s negative effects one patient at a time”.[2]

However, several of the research studies cited are more than twenty (20) years old and the sample sizes were small (60 subjects or less) which isn't a true random sampling of the general population. This in no way means the findings of these researchers is not legitimate but is dated and cannot accurately formulate a conclusive argument for or against the use of inversion tables.[3]^{, [4], [5], [6], [7], [8], [9], [10], [11]} Dr. Laskowski’s article did however include two literature reviews in which the authors searched medical databases for studies involving treatment methods for low back pain.

The first, published in 2006 in Spine, examined traction therapy for low back pain with or without sciatica. In this review the authors selected studies regarding “randomized controlled trials (RCTs) involving any type of traction”, albeit inversion tables ARE a form of traction this was not the solitary focus of this review. The authors ultimately concluded that “intermittent or continuous traction” is not a recommended standalone treatment for low back pain but that “the literature allows no firm negative conclusion that traction, in a generalized sense, is not an effective treatment for patients with LBP”.

The second, published in 2007 in the Annals of Internal Medicine, examined treatment methods that ranged from acupuncture to yoga but did not primarily examine the benefits and/or risks involved with inversion tables. The authors conclude that cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation exhibited moderate clinical effectiveness for the treatment of chronic or subacute low back pain. [12]

Ultimately I did find one [unbiased][13] research article that exclusively examined the use of inversion therapy in the treatment of low back pain. Although cited in Mr. Macpherson’s article ² it must have been an ad hoc addition by the website because this study was conducted three (3) years after the publication of his commentary. This was a pilot randomized trial conducted at the Regional Neurosciences Centre, Newcastle Upon Tyne in the United Kingdom that examined “the effect of inversion therapy in patients with single level lumbar discogenic disease, who had been listed for surgery”. Although only a small sample size (24 participants) was observed it examined the use of physiotherapy in the treatment of sciatica with and without the use of an inversion device. From a clinical standpoint the outcome measures used in this trial are right on the mark as well as their use of surgery avoidance as a sign of treatment success. The authors concluded that a larger multi-center randomized trial needs to be conducted because it was shown that “intermittent traction with an inversion device [plus physiotherapy] resulted in a significant reduction in the need for surgery”.[14]

So what does all of this mean for you, the consumer? Before commencing any form of treatment due to a spine related disorder you should first consult a licensed medical professional who is specifically trained to differentially diagnosis your symptoms. Internet websites and anecdotal advice from friends and family is not a proper substitute for professional determination of your pain and effective treatment protocol(s). In fact when it comes to inversion therapy there are several contraindications to its use such as deconditioned musculature (spinal instability, spinal injury), eye conditions (detached retina, glaucoma, infection), circulatory problems (clotting issues, heart condition, high blood pressure, atrial fibrillation), fracture, hernia, implanted device(s), middle ear infection, osteoporosis, or pregnancy and only a professional medical consult will help determine if this form of treatment is right for you.[15] You should also keep in mind that no solitary intervention, as stated in the research presented here, is an effective form of treatment for musculoskeletal pain and dysfunction.

“Inversion tables are more or less like traction. I tell patients that want to try an inversion table to make sure they have another person in attendance to help them on and off the table. The same is true with traction. It may help, it may not. Generally, you will know the first time it is used.”[16]

FredrickWilson, DO

Center for Spine Health, Cleveland Clinic

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[1] Laskowski, Edward R. "Diseases and Conditions - Back Pain." Inversion Therapy: Can It Relieve Back Pain? Mayo Foundation for Medical Education and Research, 09 June 2014. Web. 17 Mar. 2015. <http://www.mayoclinic.org/diseases-conditions/back-pain/expert-answers/inversion-therapy/faq-20057951>.

[2] Macpherson, Kevin. "Inversion Therapy." Canadian Chiropractor. Annex Business Media, 30 Apr. 2009. Web. 17 Mar. 2015. <http://www.canadianchiropractor.ca/techniques/inversion-therapy-1461>.

[3] Haskvitz EM, et al. Blood pressure response to inversion traction. Physical Therapy. 1986;66:1364.

[4] Lamarr JD, et al. Intraocular pressure response to inversion. American Journal of Optometry & Physiological Optics. 1984;61:679.

[5] Klatz RM; Goldman RM; Pinchuk BG; Nelson KE; Tarr RS: The effects of gravity inversion procedures on systemic blood pressure, intraocular pressure and anteriol retinal pressure. J Am Osteopathic Assoc. 1983 Jul; 82(11) 853-857.

[6] Goldman RM; Tarr RS; Pinchuk BG; Kappler RE: The Physician and Sports Medicine. March 1985.

[7] Nachemson A and Elfstrom G: Intravital Dynamic Pressure Measurements in Lumbar Discs. Scandinavian Journal of Rehab Medicine, supplement, 1970.

[8] Kane M, et al.: Effects of Gravity-facilitated Traction on Intervertebral Dimensions of the Lumbar Spine. Journal of Orthopedic and Sports Phys Ther. 281-288, Mar 85.

[9] Nosse L.: Inverted Spinal Traction. Arch Phys Med Rehabil 59: 367-370, Aug 78.

[10] Dimberg L, et al: Effects of gravity-facilitated traction of the lumbar spine in persons with chronic low back pain at the workplace.

[11] Sheffield F.: Adaptation of Tilt Table for Lumbar Traction. Arch Phys Med Rehabil 45: 469-472, 1964.

[12] Chou R. Nonpharmacologic therapies for acute and chronic low back pain: A review of the evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline. Annals of Internal Medicine. 2007;147:492.

[13] I did find another study published in the Journal of the Canadian Chiropractic Association but found it hard to believe no outcome bias existed when the study was funded by the manufacturer of the inversion device being used in the research.

[14] Prasad KS, et al. Inversion therapy in patients with pure single level lumbar discogenic disease: a pilot randomized trial. Disability and Rehabilitation. 2012;34(17):1473-80

[15] Spinasanta, Susan. "Low Back Pain and Sciatica Treatment | Inversion Therapy." SpineUniverse. Vertical Health, LLC, 17 Apr. 2014. Web. 17 Mar. 2015. <http://www.spineuniverse.com/conditions/back-pain/low-back-pain/turning-back-pain-sciatica-upside-down>.

[16] Wilson, Fredrick. "Osteopathic Manipulation for Back&Pelvic Pain." My.clevelandclinic.org. Cleveland Clinic, 14 Jan. 2011. Web. 18 Mar. 2015. . This is was taken from "Online Health Chat" hosted by the Cleveland Clinic where members of the general public were able to have a Q&A session with Fredrick Wilson, DO.

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