Book Review: Low Back Disorders

Low Back Disorders: Evidence-Based Prevention and Rehabilitation. 2^nd Edition. Stuart McGill, PhD. Human Kinetics, 2007. 312 pages. 

Dr. Stuart McGill and his immense research based out of the University of Waterloo, Ontario can be summarized in this 2^nd edition of Low Back Disorders.  Although, the back is often seen as complex by many health professions alike, Dr. McGill’s book helps to put things into a perspective which is easy to understand. The book is divided into three parts. Part 1- “Scientific Foundation”, part 2- “Injury Prevention” and part 3- “Low Back Rehabilitation”. 

Although deemed to be the driest aspect of the book, the “Scientific Foundation” section helps set forth groundwork in understanding the low back. Here, the reader can grasp the concept of whom, how, and why people develop back problems so frequently. With his thorough evidence-based knowledge, McGill sets the record straight on the myths and realities of low back disorders. However, despite the validity in these concepts, much of section 1 can be eliminated for the common clinician who doesn’t want to be overwhelmed in the details of research and lab instrumentation.

The “Injury Prevention” section provides light at the end of the tunnel when assessing common risk for low back injuries in chapters 8 and 9. Here clinicians are provided with knowledge that can be recommended to almost every patient. Although ergonomics is not the cause in every patients back problem, McGill helps evaluate multiple scenarios to minimize forces and injury to the spine. 

The most appealing part of the book is found in section 3 Low Back Rehabilitation. Rehabilitating the spine is often one of the greater challenges when handling problems of the low back. This section provides great exercises that can be implemented for the most common sufferer of low back pain. Furthermore, McGill provides readers with an array of tools and tests that can help clinicians determine which patients are in need of these exercises. This section alone is worth the money and time spent in reading the book. 

This book is an important read for any health professional that deals with the low back. Although 312 pages of research and science can appear daunting, this book saves many clinicians the ample time it takes to research and understand the back. However, there is much more to understanding a patient's back pain and many factors have to be considered. It should be advised that Low Back Disorders should be used as a stepping stone in comprehending what a patient is experiencing and not to be deemed the complete guide in low back health. The book also tends to saturate many of the key points which can be simplified into a few pages. Constantly, referring back to itself in past and future settings the book appears to drag on leaving the reader at times uninterested. 

In comparison, to the 1^st edition not much more is amplified as it is stated in the book. More recent research is referenced, and there are additional photos and information provided, however nothing that appears to make the book significantly more valuable.  The 2^nd edition simply updates points which were already stated to be important in the 1^st edition. With this being said, the 1^st edition can be just as valuable to the curriculum as the 2^nd. However, no matter which edition, Low Back Disorders can be recommended to enhance the insight of any clinician, scientist, or student in tackling the issue of low back injuries. Dr. Wayne Button, BSc, D.C


Boyd, K. (2003). Low Back Disorders: Evidence-Based Prevention and Rehabilitation Physiotherapy Canada, 55 (02) DOI: 10.2310/6640.2003.37832

Chiropractor Myth # 4 - Chiropractors only treat the back

This myth is a common mistake because of the disparity in the chiropractic world. Some chiropractors claim to only treat "conditions of the spine". However, like me the majority of chiropractors welcome all kinds of injuries into their practice.

So what injuries should I go see a chiropractor for?

The majority of injuries which chiropractors deal with focus on muscles, nerves and joints. Observe a list of conditions me and colleagues of mine have treated and rehabilitated in the past:

Tennis Elbow           Golfers Elbow      Shoulder Instability

Sprained Ankles      Osteoarthritis       Ulnar Impaction Syndrome

Muscle Strains        Spondylolisthesis   Facet Syndrome

Migraines               ITB Syndrome        Piriformis Syndrome

Trigger Points         Plantar Fasciitis    Carpal Tunnel Syndrome

ACL Sprains            Acetabular Tears    Hamstring Strains

Disc Herniations      TMJ Syndrome        Adductor Strains

Sports Hernia          Tendinopathies       Turf Toe

As you can see by the prior list of conditions, injuries can span from head to toe. However, one must also not underestimate the power of a diagnosis. Often patients will present with condition which can't be treated by us. Furthermore, conditions can be found accidentally on x-rays by a chiropractor. Whether or not patients are referred back to their medical doctor, a specialist or a surgeon a diagnosis can still be a rewarding experience for a chiropractor. Observe a list of conditions myself and colleagues of mine have diagnosed.

Kidney Stones            Gall Stones            Abdominal Aortic Aneurysm

Hyperthyroidism        Hypothyroidism      Multiple forms of Cancer

Multiple Sclerosis       Polymyositis           Ehler Danlos Syndrome

AS                             Reiters Syndrome   Cushings Syndrome

So why the confusion?

Much like other health professions chiropractors have different beliefs and philosophies.  Some chiropractors are subluxation based chiropractors. I am not a subluxation based chiropractor so cannot speak on their behalf. However, this particular group of chiropractors believe sickness is due to misalignments in the vertebral column known as subluxations. This is why we are commonly associated to only treat the back or the spine. However, there are multiple chiropractors who do not practice this type of philosophy.

So how do I know which chiropractors  treat more than the back?

Often best methods is to simply ask. Also, viewing a chiropractor's website or calling their office can often give you a good indication on how they practice. Furthermore, friends have no incentive to misinform you on the chiropractor they go to. So asking another patient of a chiropractor about their philosopies can be very informative. 

In summary, chiropractors can treat a wide spectrum of conditions and injuries. During my internship in school I actually got more shoulder patients than any other form of injury. This was a great learning experience and made me more proficient in this area. So next time your hurt in an area besides your back don't rule out a chiropractor as a reliable option. Dr. Wayne Button, BSc, D.C  Chiropractor Myths 1-3

                            

Are your muscles dysfunctional? Understanding Neck Pain: Part 1

   I have always been a firm believer that when it comes to diagnosing conditions one has to find the specific structure causing the pain. However, neck pain is not always so straight forward. To truly understand neck pain you have to embrace the concept that muscles work in synergy together.

   Have you ever looked deeply into the statistics regarding neck pain? If you have you might start to think nobody knows what their doing. Neck pain has been estimated to have reoccurence rates as high as 94% in some studies. This means if you were to get neck pain there is a 94% chance of you getting it again. These numbers pose a valuable question.

How do mechanical neck pain (MNP) sufferers differ then the normal population? 

   There are a number of different entities which separate those which suffer from MNP and those which do not. However, for purposes of this column we will be looking at muscle dysfunction.

    Firstly, what many people may not know is those who experience MNP have been shown to experience physical changes in their muscles. While in pain you often fail to use muscles you once used efficiently. This can lead to changes in those muscles.
    For example, studies have shown whiplash sufferers to actually have a pronounce amount of fatty tissue in their suboccipital and multifidus muscles. These muscles particularly play an important part of proprioception. Proprioception is the necks way of understanding where the head is in correlation to the rest of the body. In addition, those which experience chronic neck pain have muscles which atrophy due to disuse.
    These physical changes may explain the high reoccurrence rate of neck pain. Professionals may be focusing too much on addressing eliminating pain but not on these physical changes in the muscles

     In addition, people with MNP often have been shown to have changes in their muscles behaviours. Your body now finds a way to completely reorganize its muscular activity. Muscles that once worked in synergy together now work at different times.
 
    There are two main groups of muscles in the neck, global muscles and local muscles. Global muscles which are fairly superficial are used mostly to produce strength, force and overall stability. Local muscles are commonly deeper muscles in the neck. Local muscles are often used for proprioception and stability of the vertebral column. Basically picture local muscles as a sleeve around your vertebral column trying to protect it and keep it upright and stable. Both groups of muscles work to help keep your neck stable. What happens when one of the muscle groups aren't doing their job? The other muscle group takes over and this can lead to overactive muscles and thus pain.

    Studies have exemplified this theory again and again. Those suffering from MNP have been shown to have highly overactive global muscles. Secondly, those with MNP have also been shown to have deep cervical muscles which are inhibited. This means these muscles have a slower reaction time to firing. Such results indicate that the global muscles commonly compensate for the local muscles in those MNP sufferers.

Why is this important?
    Well now that you are using the more superficial muscles (anterior scalenes and sternocleidomastoid muscles) these particular muscles become fatigued quicker than normal. Although, all this happens at the subconscious level it can still be detrimental.
 
    A great analogy used by Stuart McGill is the example of someone getting back pain while shovelling their driveway in the winter. While shovelling muscles now have to choose between being used for respiration or stabilizing the back. Obviously, they choose respiration and now the person's back may give out or experience pain.

    So now the muscles have physically changed and altered their normal behaviour. This combination can affect a muscle's ability to produce force and function as it once did. Those with MNP have been shown to have deficiencies in maximal strength, endurance, power and efficiency in contracting muscles. What is more interesting is these deficiencies usually are evident in activities which require 20-50% maximal muscle force. This range of force is what most daily activities require. Daily activities like turning your head as you pull out of the driveway, raising your head for a sustained period to do overhead work or even just tilting your head slightly to watch TV.

    In summary, one must truly understand how muscular dysfunction can cause neck pain before attempting to treat it. If you are just focusing on reducing the pain you are simply taking a band aid approach. As professionals we should attempt to not just relieve the symptoms but also incorporate a plan so the symptoms never return. So the next time your neck is in pain try to worry about what's causing it and not the pain itself. Dr. Wayne Button, BSc, D.C

O’Leary, S. (2009). Muscle Dysfunction in Cervical Spine Pain: Implications for Assessment and Management Journal of Orthopaedic and Sports Physical Therapy DOI: 10.2519/jospt.2009.2872

Heel Spurs? Where do these things come from?

Many people claim heel spurs to be an abnormal finding. However, research dating from the early 60’s to late 90’s have reported anywhere from 11-16% of the general population to have some type of heel spur.

It’s debatable if heel spurs are strongly correlated to older age, gender and osteoarthritis. However, the debate linking heel spurs and pain has progressed to treatment involving shock wave therapy, surgical incision and even radiation therapy


The Debate: Traditionally the pathophysiology of spurs forming was based on what was called the longitudinal traction hypothesis.
         

Why the Traction Theory?: It was thought; the plantar fascia’s insertion creates traction and thus develops inflammation. Now from this inflammation reactive ossification is formed in the plantar fascia’s enthesis leading to the formation of a spur. Studies started to support this theory with the link of flatfooted people and heel pain. It was believed having a lower longitudinal arch created tension and thus the pain was created.   

Evidence for a Non Traction Theory: 1) Heel spurs have been found to be located deep to the plantar fascia rather than at its insertion point. Heel spurs have also been shown to be closely related to other muscle insertions such as the quadrates plantae, flexor digitorum brevis and abductor hallucis. Some heel spurs are not even correlated to muscle insertions but rather found within fibrocartilage and loose connective tissue.

2) Excised plantar fascia doesn’t show histological evidence of inflammation

3) Bony trabeculae have not been found to align in a direction of traction

4) Excised spurs have been shown to reform after a surgical released plantar fascia.                                                                                                                                                                                                                The alternative theory:Another theory can be one of vertical compression hypothesis (Kumai & Benjamin) which purposes a heel spur is due to compressive forces rather than traction. They suggest heel spurs are fibrocartiligenous overgrowths that occur in response to a microscopic stress fracture. These overgrowths are simply the calcaneus’s way of protecting itself from micro cracks.  

 

Support: Heel spurs are more common in subjects which are overweight and have decreased elasticity in their fat pads. Furthermore, histological studies on cadavers have shown bony trabeculae of spurs to be vertically aligned as if compensating for a compressive force.     

 

The research: A recent study involving 216 subjects found further support for a compressive hypothesis. Subjects were over the age of 62 and had either a heel or achilles spur. The spurs were found to be correlated to obesity (BMI), osteoarthritis and pain. However, there was no significant correlation found with foot posture (x-ray measures). Obese and OA findings indicate compressive forces may be involved. The lack of foot posture being correlated also strengthens the argument. If traction was the main culprit all those with flatfeet would have been strongly linked.                                                                                                                                                                                                                                                     To rebuttal those studies which also link obesity and a low longitudinal arch this factor may be argued to be more so related to the biomechanical properties of pronation.                                                                                                                                                                                                                                   

  The findings of pain don’t really indicate either theory. This again strengthens the whole controversy of what actually causes the pain from a heel spur. Is it the spur itself or the soft tissue around it?                                                                                                                                                                                                             

What about the anatomy? Studies have found almost any variation of where a heel spur can lie in the foot anatomically. However, the more recent research supports a theory of compression where heel spurs are not always found within the plantar enthesis.  The most recent study inspected 37 spurs in 20 cadavers. Multiple variations were found using different forms of imaging. This study purposed that the cause of a spur isn’t necessarily traction and much more complex then probably previously thought. They found spurs to form when surrounded by loose connective tissue. Furthermore, those spurs aligned with the plantar fascia’s enthesis didn’t always have a bony trabeculae pattern which replicated a cause of traction forces. Some heel spurs had a basket weave like patterns.                                                                                                                              This pattern supports wolfs law regarding bony articulation taking on the form of dynamic stress. In summary, we now have strong implication to believe heel spurs are more so due to compressive forces. The clinical significance of these findings is significant. One has to find the cause of a diagnosis before aiming to treat it. If the traction hypothesis is correct one may aim to limit such forces by releasing the plantar fascia with stretching, aggressive soft tissue therapy of surgical incision. However, if due to compressive forces one may aim to treat the injury like a stress fracture focusing on relative rest and an orthotic designed to decrease forces. Dr. Wayne Button, BSc, D.C

Li, J., & Muehleman, C. (2007). Anatomic relationship of heel spur to surrounding soft tissues: Greater variability than previously reported Clinical Anatomy, 20 (8), 950-955 DOI: 10.1002/ca.20548 Li, J., & Muehleman, C. (2007). Anatomic relationship of heel spur to surrounding soft tissues: Greater variability than previously reported Clinical Anatomy, 20 (8), 950-955 DOI: 10.1002/ca.20548 Menz, H., Zammit, G., Landorf, K., & Munteanu, S. (2008). Plantar calcaneal spurs in older people: longitudinal traction or vertical compression? Journal of Foot and Ankle Research, 1 (1) DOI: 10.1186/1757-1146-1-7

Meralgia Paresthetica: Finally There is A Test I Can Do On My Patient

Meralgia Paresthetica (MP) is a mononeuropathy (pathology of one nerve) occurring to the lateral femoral cutaneous nerve.  The condition causes paresthesia and numbness over the anterolateral aspect of the thigh.  MP is a neurological condition which is caused commonly by a nerve being “entrapped”  near its surroundings or origin. The nerve itself may get compressed by the inguinal ligament, tensor fascia latae and psoas.

The most interesting aspect of meralgia paresthetica is the multiple different causes. MP has been reported to be caused by obesity, pregnancy and compression from tight pants, belts, uterine fibroids and tumours. Furthermore, MP can be due to direct trauma, surgery complications and even associated with disorders such as diabetes and leprosy. [2]   Recent reports have also surfaced regarding MP being causes by exercise [1].

However like most neuropathies, MP may produce arbitrary findings and examination results. It is often hard for a manual therapist to perform a test which confirms his or her suspicion of Meralgia Paresthetica. Most neuropathies don’t follow a perfectly mapped out distribution of symptoms. MP can often be mis-diagnosed as a radiculopathy or a referral pattern from pathology of the gluteus medius muscle. Nerve conduction studies can often help confirm one’s diagnosis but are not easily accessible to manual therapist.  The following is a fairly new test which can be used by manual therapist to help diagnose Meralgia Paresthetica.

Pelvic Compression Test [3]

This test is based on the premise the LFCN is compressed by the inguinal ligament and by relieving this compression symptoms will temporarily be alleviated. With the patient focusing on their symptoms the examiner attempts to apply a downward and lateral compressive force on the pelvic. The pressure is held for 45 seconds and a positive result is when patients report an alleviation of their symptoms. By compressing the pelvic in this manner the two attachments of the inguinal ligament are brought closer together causing the ligament to become slacker.

This test was only performed on a small number of subjects (20) who were confirmed to have MP by electrophysiological studies. However, 19/20 patients confirmed patients received a positive test result. The validity of the test stood to have a sensitivity of 95% and specificity of 93.3% making it the only valid test to date which can be used by manual therapist. The only downfall of the test is the patient has to be presenting with symptoms in order for it to be performed and MP confirmed.   In summary, the study only has a small subject size and wasn’t only designed to look at this one entity. However, due to the lack of other testing procedures at our exposure in the literature for this condition I feel it is a test worth trying. So the next time a patient comes in with symptoms down their leg see if you can relieve it. Dr. Wayne Button, BSc, D.C

Kho KH, Blijham PJ, & Zwarts MJ (2005). Meralgia paresthetica after strenuous exercise. Muscle & nerve, 31 (6), 761-3 PMID: 15654691                                                                                                                                                                                                            Harney, D., & Patijn, J. (2007). Meralgia Paresthetica: Diagnosis and Management Strategies Pain Medicine, 8 (8), 669-677 DOI: 10.1111/j.1526-4637.2006.00227.x                                                                                                                                                                     Shimizu, S. (2008). A Novel Approach to the Diagnosis and Management of Meralgia Paresthetica Neurosurgery, 63 Kho, K., Blijham, P., & Zwarts, M. (2005). Meralgia paresthetica after strenuous exercise Muscle & Nerve, 31 (6), 761-763 DOI: 10.1002/mus.20271