Chiropractic Care for Low Back Pain

Steven G. Yeomans, DC

Grant Cooper, MD

Spine-health.com expert featured on Back Pain Radio

Common causes of low back pain include problems with the facet and sacroiliac joints, as well as disc problems. Chiropractic care can be a conservative treatment for all of these. Dr. Steven G. Yeomans, D.C., a chiropractor in Wisconsin and a Medical Advisor and contributing author for Spine-health.com, and Grant Cooper, M.D., host of Back Pain Radio, discuss the role of chiropractic care as part of an integrated approach to treating low back pain on the May 9, 2005 show.

Transcript of Back Pain Radio show on Chiropractic Care for Low Back Pain

Below is the transcript summary from the Back Pain Radio show on chiropractic care for low back pain, broadcast on May 9, 2005.

Most common causes of low back pain

Dr. Cooper:

When I talk with orthopedic surgeons and physical medicine doctors about the causes of low back pain, I often end up discussing the disc, facet joints, and sacroiliac (SI) joints as the most common causes. Coming from a chiropractic perspective, what are the most common causes of low back pain?

Dr. Yeomans:

Well, I think I’d have to agree with the others that the origin or the generator of low back pain is typically in those three structures, SI, facet, and disc, and then we can argue or we can discuss which one is the biggest player. I think from a mechanical low back pain standpoint, probably 80% of our patients with back pain present with usually a joint condition, such as a facet or an SI, and maybe the remaining 20% are obviously discogenic. Then of the 80% mechanical presenters, probably half of those have some disc tearing or some internal, but contained, derangement of the disc that looks like it’s a joint problem.

Dr. Cooper:

Interesting. As you mentioned, we could certainly discuss and debate those numbers, but it sounds like overall there is a general consensus on what’s causing the pain in most cases, and then there would be different approaches on how to treat that. Would that be fair?

Dr. Yeomans:

Yes, that would be very fair.

Chiropractic treatments for a typical case of low back pain

Dr. Cooper:

Okay, so I’d like to present you with what I think is a typical case of a patient with back pain, and then walk through how you would approach treating the patient, including when you would suggest or not suggest bringing in other doctors from perhaps different disciplines to help treat the patient.

Let’s say the patient’s name is Tom, and Tom’s a fifty-year-old man who comes to you and says his back’s been hurting for about a month. He doesn’t have any leg symptoms, and he’s been in good health otherwise--a pretty typical case of mechanical back pain. He hasn’t really tried any treatments yet; he’s maybe taken some over the counter medications. What would be the first thing that you would offer Tom, or are there other questions you’d like to ask him?

Dr. Yeomans:

Well, when patients present, we typically have them complete the myriad of paperwork that patients are bombarded with, and after vital signs are taken, then we elaborate on their history. You’ve already indicated that there’s no leg pain, and that’s one of the first things we try to distinguish. We can do that by looking at pain drawings or we can do it by history. If he’s a first time patient without a significant amount of yellow flags or psychosocial factors, it’s probably pretty straightforward. I may even elect not to x-ray if he’s in good health and an exerciser, but at age fifty-plus, we have to be concerned with other causes of low back pain other than physical causes and that might prompt me to take an x-ray, but that would be case-specific.

Dr. Cooper:

By other causes, you’re referring to possible cancer?

Dr. Yeomans:

Right, cancer being a biggie. The red flags of low back pain are cancer, fracture, cauda equine (caused by compression of the nerves in the lower spine, which can result in paralysis if left untreated), and infection. These are things none of us in any discipline ever want to miss because of their catastrophic results. But generally those, thank goodness, aren’t too common, and then we can proceed with a physical examination. In this presentation I’d expect a person to, if he’s not too acute, feel better in forward flexion, feel worse in backward bending, and have no radiation of symptoms into the legs during maneuvering, and that the reflexes and muscle strength in the lower extremities are intact. If this is the scenario, I would probably proceed with some passive approach immediately, meaning manipulation, maybe some physical therapy modalities to reduce any concurrent splinting of the muscle or any pain factors that might be present. I might set him up for a treatment schedule of two or three times a week for a week or two to see how it calms down. During that time I would present some exercises into his lifestyle. A lot of our emphasis is on patient education to help them understand that once they have this, they’re four times likelier to have a repeat episode, and so teaching them how to bend, lift, pull, push, and what exercises from a hygiene standpoint would help their back, are a strong emphasis in this type of simple kind of case. And then we try to emphasize preventative techniques.

Dr. Cooper:

How long would you go on treating Tom in this scenario, assuming that he’s not responding, and understanding, of course, that most people will respond to that treatment? Assuming he’s not responding, how long would you continue to treat him in this way?

Dr. Yeomans:

Well, there are numerous publications about case management of back pain, and I kind of embrace a two week trial with my usual approaches, and if the patient’s satisfaction is appropriate, we continue to a point of conclusion. If there’s dissatisfaction and if their pain scale reports are still high, and if their disability scores and outcome tools are still fairly activity-intolerant, then I’ll consider either another two week trial using a different approach or I’ll think about some pain-management strategies in that area. I might elect to discuss, if they haven’t tried over the counter meds at this point, that that might be appropriate, or talk to them about coordinating care with their family practitioner for some prescriptive meds, depending on their gastric tolerance to NSAIDs (non-steroidal anti-inflammatory drugs) and other drugs, but that would be, I think, a first line of defense. If that fails, then I work with a multi-disciplinary group and bring in the physiatrists for pain management and that could include injection therapies to try to identify the pain generator and then gauge the pain, hopefully, and then perhaps some more tolerable manipulation can be done if there’s reason to do that.

Dr. Cooper:

Now, I want to get to the idea of incorporating injections with manipulations in a second, but before we do that, do you have a sense of what percentage of patients improve with the most conservative approach for the first two weeks or maybe even the first four weeks?

Dr. Yeomans:

I would say a large percentage, certainly well over 50%, and it totally depends on their profile, meaning their presentation with prior episodes and yellow flags. The caution flags that can become barriers to recovery are multiple and include so many different things: illness, behavior, job dissatisfaction, lengthy prior history, depression, anxiety, marital distress, monetary distress, and the list goes on and on. Those are the barriers that seem to really keep a case from resolving to an appropriate end point, so I would guess 60% to 70% are going to be fully satisfied by that fourth week.

Chiropractic care along with injections and after surgery

Dr. Cooper:

Now, say you’ve got the patient who falls into the 30% category, who, after four weeks, is still having the pain. At that point you were mentioning perhaps referring to a physiatrist as well as continuing care with you. What kind of injections might you ask the physiatrist or other injectionist to perform?

Dr. Yeomans:

Well, if their pain is localized directly over the sacroiliac joint and different tests suggest that area to be my diagnosis, I would recommend a sacroiliac injection pretty specifically. If it’s a combination of facet and SI joint, there may be a combination injection recommended. Of course, I certainly tell my patients that two heads are better than one and three are better than two, so I see what the physiatrist has to say and see if they agree with me. If it looks like a high lumbar facet joint, we’ll try to isolate the level as much as we can with localized palpation, deep palpation to see if it elicits a pain response, but sometimes the referred pain patterns from these joints can carry over two to three segments. If it’s really acute, it can carry over the entire lumbar spine, the buttock, and the posterior upper leg, so sometimes it’s hard to isolate the pain generator. Then, selective blocks to determine the pain generator might be a way to start.

Dr. Cooper:

If you have selective blocks of, let’s say, the SI joint, would you go right into manipulations after that or would you pursue some other kind of modality?

Dr. Yeomans:

Again, that’s kind of case-specific. If I haven’t been able to manipulate the SI joint because of pain reasons, pain-generating reasons, I might elect to do it as soon as possible, because the effects of the injection, sometimes they’re immediate and sometimes there’s a two-to-three day lag and sometimes there’s a week lag. I would certainly tell the patient that when they feel that the injection is kicking in and the pain levels drop down to something less than a five on a ten scale, or something that they can measure or compare to their current status, then that would be a good time to at least place the patient into a position that I would typically use. There are also less forceful approaches that sometimes I can use even when they’re more acute, that I’ll usually try before I ask for the injections, but they don’t always work either, so the injections often are a really good pain management strategy.

Chiropractic care after disc fusion

Dr. Cooper:

Excellent. Dr. Yeomans, there are so many questions that I want to get to, but I can’t because they’re telling me I just have a minute left. There is one question in addition that I’d like to ask you real quick, if I may. In a patient that’s had fusion surgery previously, so this is a different patient altogether, can that patient still have manipulations, or does a fusion, or perhaps a laminectomy, preclude manipulation therapy?

Dr. Yeomans:

As a rule, fusion does not, in and of itself, contraindicate that patient from manipulation. I would like flexion extension x-rays to see if there’s stability above the fused segment to make sure the fused segment is not unstable and, generally speaking, I don’t see a whole lot of instability or hypermobility to a pathological degree above the fused area. I’ve often manipulated patients post-fusion very comfortably and safely. Bottom line is you set the patient up, and if the set up feels good, the actual manipulation isn’t a whole lot more than what the end point of the set up is.

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