Dr. Dalfino's Non-Surgical Treatment Blog

Low Back Pain And Its Many Causes!!!

Low back pain (LBP) is one of the most common complaints presenting to our office and remains one of the most challenging conditions to manage because there are so many causes of LBP.  Some of the causes include the obvious such as over lifting, over use activities such as sports injuries (bowling, golfing, skiing, tennis, football, etc.), raking leaves, shoveling snow, and more.  Frequently, work related strains are the primary cause of LBP due to the constant, persistent and awkward positions frequently required in many jobs, especially in repetitive motion assembly line work.

The cause can also be as simple as standing on 2 feet vs. 4 feet.  Studies show when 2 legged and 4 legged animals are compared, arthritis starts in the 3rd vs. the 6th decade of life, respectively due to the vertical load placed on the biped or 2-legged animal. In spite of this, after sharing this information with patients, I have not been successful in convincing them to start walking on all fours!  Because we are a 2-legged species, addressing a short leg can have significant benefits to any spinal condition.  This is because a short leg of only 5mm (1/4 inch) can result in a drop in the pelvis resulting in crooked foundation that the spine sits on, creating a curvature in the spine.  This places stress on the spinal components including the spinal cord and nerves and can contribute or be the actual cause of not only LBP, but also problems higher in the spine including neck pain and headaches! 

Many times, a satisfying outcome is not achieved until I address the leg length issue by the use of heel or a combination of heel & sole lifts.  If a leg is short, the effects at the top – that is, the neck and head, are dramatically affected.  In one case, treatment to the neck and head had little effect on his headaches and only after placing a heel lift in one shoe and arch support in both shoes did he feel significantly improved.

In most cases, treatment addressing the entire body from the feet up yields the most satisfying results.  Also, secondary issues such as diet, stress management, home treatments including exercises, can be very important in the successful management of back pain.  In many patients, a combination of chiropractic, leg length correction, and nutritional management including the use of vitamin and herbs resulted in the best approach results.

Usually, offering the patient advice on the methods of applying ice, modifying/reducing bending/ lifting activities, as well as performing the chiropractic treatment will satisfy the majority of patients. However, in some cases, co-management with other allied health care providers is necessary, especially where there is a slow response in the initial acute stage of LBP. If these less common cases should occur, the combination of chiropractic and primary care yields the best results.

In our clinic, we offer a multidimensional, holistic approach to the treatment of low back pain so that a positive, satisfying outcome is achieved.

Low Back Pain (…or is it?)

Have you ever had leg pain and immediately blamed your low back?  Me too!  Many patients (and unfortunately, many doctors) conclude this to be “sciatica” or a “pinched nerve.”  When this diagnosis is wrong, it can lead to an inappropriate type of treatment, delaying appropriate care, or worse, it may result in death due to a missed diagnosis of a blood clot.  There is currently a government campaign seeking to warn the public about this hard-to-diagnose 'silent killer.' 

Here’s the news flash that was recently released (updated 8:28 a.m. CT, Mon., Sept. 15, 2008):  “WASHINGTON - Far too many Americans are dying of dangerous blood clots that can masquerade as simple leg pain, says a major new government effort to get both patients and their doctors to recognize the emergency in time.”

"It's a silent killer. It's hard to diagnose," said acting Surgeon General Dr. Steven Galson, who announced the new campaign Monday. "I don't think most people understand that this is a serious medical problem or what can be done to prevent it."

Blood clots make headlines when seemingly healthy people collapse after prolonged sitting, such as long airplane flights or being in similarly cramped quarters. Vice President Cheney suffered one after a long trip last year. NBC correspondent David Bloom died of one in 2003 after spending days inside a tank while covering the Iraq invasion.

According to the Surgeon General’s new campaign, there are about 100,000 deaths associated with blood clots each year. Risk factors include increasing age (especially over 65), recent surgery or fracture, falls, car crashes, prolonged bed rest, smokers, obesity, pregnancy, and hormone replacement drugs including birth control pills. Other less controllable causes can include genetic conditions so it is important to tell your doctor if a relative has ever suffered a blood clot.

People with these factors should have "a very low threshold" for calling a doctor or even going to the emergency room if they have symptoms of a clot, said Galson, who issued a "call to action" for better education of both consumers and doctors, plus more research.

Symptoms include swelling; pain, especially in the calf; or a warm spot or red or discolored skin on the leg; shortness of breath or pain when breathing deeply.  Unfortunately, studies suggest only a third of patients who need protective blood thinners for major surgery get them. And patients can even be turned away despite telltale symptoms, like what happened to Le Keisha Ruffin just weeks after the birth of her daughter, Caitlyn. In her case, after being turned down by several visits to the doctor and ER, only after a very hot bath did her leg swell to 3-4 times its normal size, tipping off the doctors to make the right diagnosis.

Don’t wait for your medical doctor or our office to make the diagnosis if you’re suspicious of a blood clot.  Ask us if it’s a possibility. Rest assured that we have been properly trained to diagnose this condition and we work with other health care providers when needed.

Did You Know This About Low Back Pain?

If you have low back pain (LBP), you are certainly not alone. Almost everyone at some point has back pain that interferes with work, daily activities, and/or recreation. Americans spend at least $50 billion each year on LBP.  It is the most common cause of job-related disability and a leading contributor to lost work time. Back pain is second to headaches as the most common neurological condition in the United States.  Fortunately, most occurrences of LBP go away within a few days. Others take much longer to resolve or lead to more serious conditions (1).

There are two types of low back pain – acute and chronic.  Most episodes of acute LBP last from a few days to weeks, are not neurological and usually do not carry a high level of surgical risk. The cause of LBP can be difficult to isolate because often, while the cause is cumulative where multiple events over time, the last activity the patient recalls is “bending over for a pencil.” This, by itself is not likely to cause an acute onset of LBP.  Low back pain can be caused by trauma such as sports injuries, work around the house such as garden work, car accidents, and others. Chronic low back pain, by definition, is LBP that lasts more than 3 months and the cause can be more difficult to identify and is often cumulative and superimposed on a prior condition such as degenerative disk or joint disease.  A real problem is the rate of recurrence or, chronic, recurrent low back pain where pain may subside but returns at various rates of frequency and duration.  This category affects a high percentage of the population and represents the true challenge in spine care management (1, 2).

As people age, their bone strength and muscle stretch, strength and tone usually decreases due to lack of activity. When the disks begin to lose fluid and flexibility, their ability to cushion the vertebrae and function as “shock absorbers” also decreases. Disks can tear, bulge, and/or herniate which results in localized LBP and/or radiating pain that follows the course one or more of the 31 pairs of nerve roots (eg., “sciatica” down the back of the leg).  Soft tissues such as joint capsules and ligaments lose their capacity to stretch and can tear more easily, resulting in a sprain or strain (muscle/tendon injury). Other conditions that either cause or contribute to LBP include arthritis, obesity, smoking, pregnancy, stress, poor posture and/or physical health, and can lead to unsatisfied patients if these co-contributors are not properly identified and discussed.  Less commonly, LBP can be caused by a more serious condition such as cancer, fracture, infection, spinal cord compression, and various internal conditions (3).  Emergency care may be indicated in these circumstances.

 Your doctor of chiropractic will perform a complete examination, consider other contributing causes, and will treat the problem(s) causing the LBP condition.  If needed, working with other allied health care providers will be arranged.  Exercise, dietary recommendations, ergonomic or work modifications, spinal manipulation, and modalities will all be considered to help eliminate or control of the LBP. Methods of self-managing the LBP will be emphasized.

1. http://www.ninds.nih.gov/disorders/backpain/detail_backpain.htm
2. http://www.spine-health.com/conditions/lower-back-pain/lower-back-pain-symptoms-and-treatment-options
3. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline. Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1994.

Alternative to Back Surgery?

A recent large-scale study from Great Britain has results that’ll make you wonder whether back surgery is always necessary (Bhattacharyya M. Does the risks and benefits of spinal manipulation in patients with low back pain as a nonsurgical approach translate into better outcomes in routine clinical care: a prospective observational cohort study. J Bone Joint Surg 2008;90B:Suppl.492.). One hundred two patients were followed while they waited to see a spinal surgeon. The patients had disk herniations confirmed by MRI and had sciatic/leg pain. They had also previously tried 4 weeks of medications (non steroidal anti-inflammatory drugs), which had provided no benefit.

While they waited to see the spinal surgeon, they were referred for manipulations provided by experienced chiropractors. The adjustments were given five days per week.

A few patients had some transient increase in pain and there were three treatment failures (out of 102). Overall the results were very encouraging with patients moved off of the surgery wait-list.

But how is this possible? The disks are the hard cartilage separating each vertebra in your lower back. When this ligament sprains it can bulge onto a nearby nerve, causing back pain or pain down your leg. Precise adjustments use the bones as levers to affect the alignment of these vertebrae and the movement of the joints in the lumbar spine. If alignment is improved, then there is better posture and distribution of loads. When the mobility is more symmetrical, this also may prevent unequal loading of the soft tissues. Helping these mechanical aspects to heal can be enough to lessen your pain and help you to regain your quality of life. In some cases, it seems it may even keep you from a potentially unnecessary back operation.

Based on the results of the study, anyone without need of emergency surgery should try chiropractic care before having an elective operation for a disk or sciatica/leg pain disorder. Emergency problems would be symptoms like bowel and bladder dysfunction and numbness over the tailbone or hips. Most patients do not fit into the emergency-surgery camp.

If you would like to schedule a complimentary consultation to discuss your complex back problem, or you want a second opinion before trying surgery, just call. We are available at 203-922-2977 to make an appointment so that you and the doctor can discuss your individual health concerns.

If You Have Back Pain…Do You Really Need An X-ray?

Most chiropractic patients have x-rays taken of their lumbar spine. Since x-rays do carry a very small risk of tissue damage, this risk needs to be outweighed by benefits. So, how are x-rays used in our clinic?

First, x-rays can tell us about medical conditions that may require referral to another health care provider such as a spine tumor or an infection. Fortunately, these diseases are very rare, but they do need to be considered in every patient, especially those who may have certain "red flags" such as back pain at night or rest, or if there is also a fever. In addition, certain severe traumas (like a fall) can produce fractures. In an older adult with osteoporosis, or someone taking steroid medications over years, even a minor trauma event can be enough to cause a break, because the bone is in a weakened condition.

After these very rare conditions are ruled out, your x-rays can provide important information about your anatomy and physical posture. For example, curvatures of the lumbar spine, such as scoliosis, are virtually undetectable without an x-ray. If we know how your spine is deviated, this information can help direct the adjustment more specifically. Sometimes leg lengths are uneven and a person may require an orthotic  (arch support) or heel lift to level the foundation for your spine. About one in ten patients will have an unequal leg length of a centimeter or more.

In terms of the bone anatomy, x-rays can show the planes and angles of the disks between bones and whether any degeneration is present. If the degeneration is advanced, then a natural bone fusion may be present. It should be obvious that if the spinal anatomy does not allow movement or if the joints are literally fused movement is impossible, then  adjustments are not appropriate.

X-rays can also show us how one area of the spine mechanically compensates for a deviated area below. Sometimes, pain may be present at compensatory areas but without knowledge of the cause of this deviation, care may be less optimum. Just as the lumbar spine may compensate for a pelvic problem, so to can a neck condition be caused by abnormal postural lower down the spine. The x-rays can show us how case management needs to be altered to reflect your individual needs.

In any case, x-rays are important to reach an accurate diagnosis, which is the first step on the road to recovery and regaining your vitality and quality of life.

If you'd like to schedule a complimentary consultation to discuss your health concerns just call 203-922-9277 to make an appointment.

"Low Back Pain: Is It Serious?"

Back problems can cause a good deal of worry and for good reason. Any problem that doesn't go away on its own in a reasonable period of time should be a cause for concern. Rarely, severe back pain can be caused by tumors and other destructive processes, so it's important to have these serious conditions ruled out with a thorough examination and x-rays or other imaging.

The other serious aspect of back pain, much more common than a spinal cord tumor, is how it can affect your quality of life, often with devastating consequences. Research has shown how disabling severe back problems can be. In terms of quality of life, the decrease can be even more than that seen with heart and lung problems. This may not seem correct at first glance, but if you think about a back problem making you unable sit or function at work, or basically being able to enjoy life, then it becomes more understandable.

The trouble is, many of us think lying on the couch will do the trick, or taking aspirin every day is a good long-term solution.

Sprain subluxations that displace the joints of your spine are sometimes referred to as mechanical disorders. These can be detected by analyzing how your spine moves in a precise manner. Sometimes x-rays can show displacements of the lumbar vertebrae or pelvic bones.  X-rays are taken from two angles to see the alignment of the spinal joints. X-rays can also show bone destructive or degenerative processes that help to diagnose your problem, and show if adjustments are indicated.

We direct our care at improving the posture and mobility of the spine as a way to speed recovery. We find that just addressing the pain with medications or adhering to strict bed rest can be counter productive. The adjustments are applied in a careful and specific manner. As the loads on the spine are more equalized and as joints begin to exhibit more flexibility, the body is placed in a more optimal environment for healing. Since self-care is also integral to our approach, we will encourage proper stretching and exercises to help maintain and extend what we can do in the clinic.

If you would like to schedule a complementary consultation and begin getting serious about helping your low back problem, just call 203-922-9277 to make an appointment.

"Low Back Pain: Could Your Feet Or Hips Be At Fault?"

The body is an interconnected whole and needs to be looked at as such in order to get at the root of a spinal problem. We are all familiar with low back trauma, bending and stooping in awkward positions to lift something from a trunk, or the slip and fall on ice. In these examples, it's easy to see how the trauma preceded the low back pain.

But sometimes pains in the low back are not so easy to figure out. One area of the spine could be compensating in posture for another, inhibiting a vertebral joint's ability to fully recover. Or maybe you're suffering from the cumulative affects of microtrauma over time.

Such is the short leg; about 1/10 people will have an anatomic difference in leg length of up to one centimeter. This short leg causes the pelvis to incline to one side providing an uneven support for the base of your spine. It's a little like walking with one foot in a small ditch. The uneven pelvis then causes a lumbar scoliosis, which must be further compensated from above.

But a short leg can also be functional, due perhaps to a small or collapsed arch of the foot. This can account for up to 5 mm of leg length difference. Do you have a history of having flat feet or have you ever sprained one of your ankles? The sprained ankle can damage ligaments to such a degree that the normal arch of the foot can no longer be maintained.

Depending on the degree of the problem we may be able to help your low back pain by correcting a problem in the foot. Many in-shoe orthotics are available to correct a fallen arch. If the problem is very severe, you may also need a visit to a podiatrist.

In any case, it's important to consider the foundation of a spinal problem, and it can be as simple a problem as bad foot posture that is affecting how your low back functions. Also, problems in the sacroiliac joint or hips can affect how the lower spine moves.

So pay attention to where the pain is located, but also consider that other joints nearby may be affecting your recovery as well.

As a doctor of chiropractic, my office is fully equipped to handle problematic low back conditions that don’t seem to clear up in response to what you've tried in the past. Have your feet been checked? Has someone looked at your posture carefully?

If you would like to discuss any health concerns, our office can assist you in taking the next step to better health with a complimentary consultation. Just call 203-922-9277 to schedule an appointment.

"Preventing Low Back Pain"

While 80% of us will suffer a severe back pain episode at some point in our lives, most of us at any given time should be more concerned about preventing or aggravating back pain, rather than resolving a set-back. As they say, an ounce of prevention is worth a pound of cure. There are two aspects to prevention of back pain: keeping strong and flexible, and avoiding mistakes during movements.

As far as exercise is concerned, nothing is more beneficial to the spine than walking. Remember that your spine is your "core," and the core is activated with fast-paced walking. Most of us don't think of how the spine is affected with walking, instead focusing on the legs. Make walking part of your daily routine. Walk a few blocks or across town to run an errand, rather than getting into a car for these short trips. Park a few blocks away when you have to use the car, so that you can get in a few minutes of walking. Some of us spend five minutes circling in a parking lot just to get a space close to the front door or we get frustrated when we can't find a space close to the gym! In contrast to sitting, which increases pressure on our disks, walking strengthens muscles and dissipates the pressure on our lower disks.

Keep the back flexible through slow stretching in all of the different ranges. Tight muscles at the back of the thighs-the hamstrings are an often neglected area that affects the lower spine tremendously. To stretch these muscles, stand upright and put on foot on the back of a chair or sofa. Slowly bend forward and hold this position for 30-40 seconds. It should cause a tight burning pain at the back of the leg. It should not cause a shooting pain down your leg, or increase pain in the lower spine. If it does, then see a health care provider immediately. When the hamstrings are flexible, this allows the pelvis to rotate forward when you bend over. If the hamstrings are not flexible, then the lower spine will bend too much to accomplish any lifting task.

The second aspect to preventing back pain is avoiding mistakes, such as lifting with your back, instead of your legs. This is especially true if an object is very heavy. Sometimes the object is light, but we lift in an awkward position, standing with most of our weight on one leg, then bending and twisting, such as getting grocery bags from a back seat, or moving and positioning a child safety seat. Especially avoid twisting motions of the lower spine while bending over. Also, use one of your hands to help brace your spine, which will decrease the pressure on your disks.

If you would like a complimentary consultation to address your health concerns, just call 203-922-9277 to schedule an appointment.

" Low Back Pain and Excessive Weight "

Two things that are epidemic in the U.S. are low back pain and obesity (being overweight). The two go hand-in-hand and while excessive weight may not be the only cause of your pain, it does makes matters worse by aggravating your pain through increased loading the disks of the low back. In addition, most people with low back pain or who are excessively heavy are also very inactive. The first step is to perform movements that don't increase pain. For most people, walking can still be done. If your back hurts when you walk or you are so heavy, that walking causes your knees to ache, then you may need to start by walking in a pool. The important thing is to get moving because weight-loss will be helped if you can burn more calories. Walking will also improve the strength of your low back muscles, which may lessen your pain, making exercise more possible. Over the years, the gradual increase in our waist size just sort of creeps up on us. When our back begins to give way, we then realize what a barrier being overweight has become. Getting rid of your excessive weight is a simple formula of burning more calories than you consume. But, losing weight is not easy. Your genes will tell you to consume more because eating less than you need in a given day is not life sustaining. If you ate 500 less calories than you need each day, after a year or so, you'd be down to 80 or 90 pounds (depending on where you began) and eventually you would die. This is what you are up against when you're losing weight. The body tells you “don't do this” and gives you the craving to eat what you need. Despite this self-preservation mechanism, losing weight is possible and getting down to a proper weight is doable. For some people, psychological issues may be more at play. Do you eat to cover up or distract you from pain or anxiety? Are you really hungry, or has eating become a way to compensate for something more painful or difficult to confront? To get you back on track we offer complimentary consultations to see if what we have to offer in restoring your health will be a good fit in meeting your needs. Getting you back to health and losing weight are long-term processes that will require considerable effort and partnership on your part. Just call 203-922-9277 to schedule an appointment.

" Low Back Pain: An Ice Pack or the Hot Tub? "

Many patients do some self-care when they first hurt their lower back, hoping this will keep them out of a doctor's office. Home remedies sometimes make the pain go away and sometimes they don't. It depends on what you try. When the back is first hurt, it's often a sprain/strain type of injury with accompanying muscle spasm.  When a nerve in the low back gets pinched or irritated, the body will protect the delicate nerves by keeping you from moving and risking further nerve injury. The easiest way for the body to do this is to cause the back muscles to spasm and splint the injured area. Muscle pain can be quite severe and heat can sometimes soothe muscle pain. For this reason, many patients take to the hot water bottle or the hot tub to try and get some relief. This should be avoided in an acute injury because inflammation is present. With inflammation, there is increased heat and the additional heat you provide is like adding gasoline to a fire. The results are usually not good. A better choice with an acute injury is to ice the area, but this also needs to be done with some caution. The simplest ice pack is ice cubes placed in a plastic bag. While effective, you can cause a frostbite injury if you leave the pack on for too long. When you first ice the area, you will go through several phases before some pain relief is achieved. At first the pack will feel cold. The next phase is a burning sensation and the ice will almost feel hot. This is followed by an aching or throbbing sensation. Just before the area is numbed, a very sharp pain will be experienced followed by the relief you desire. This can take from five to ten minutes to go through all of the phases. Once numbness is achieved, the pack should be removed. You should most definitely not fall asleep while the pack is on. If this simple procedure does not solve the problem it's best to get your spine checked by a doctor of chiropractic. Back pain is the most common problem we treat in our office. You can always schedule a complimentary consultation to discuss your health concerns, and the different techniques we use in our office to help get you well again. Just call us at 203-922-9277 to make an appointment.