Lower back pain can be localised to only the low back area or the pain can travel down the leg also. Localised lower back pain is often less complicated and usually has a more favourable prognosis for complete recovery. During your Chiropractic consultation, a large portion of the history and examination is focused on this differentiation between back pain and leg pain. This week's article aims to explain the different types of leg pain that can occur with different lower back conditions.
We’ve all heard the word “sciatica”. It is loosely used to describe everything from lower back pain coming from the facet joints in the back, from the sacroiliac joints, from the muscles of the low back, and even from compressed nerves caused by a ruptured disc in the lumbar spine.
For the sake of accurcy, the term “sciatica” should really only be used when the sciatic nerve is being compressed. The sciatic nerve is comprised of five nerves (L4, L5, S1, S2, S3) that come from the spine and sacrum and join to form one large nerve called the sciatic nerve. True sciatica occurs when any one of the five small nerves or the larger sciatic nerve itself becomes irritated or compressed. There are many causes for this irritation, such as a lumbar disc herniation, a mal-positioned vertebra aka "a spondylolisthesis", pressure from an arthritic bone spur growing off the vertebrae where the nerve exits aka “spinal stenosis”.
"Pseudosciatica" is caused by compression of the sciatic nerve by the piriformis muscle where the nerve passes under the buttocks. Other “pseudosciatica” causes include pain referred from the facet joints of the lower back which the patient often describes as a deep ache felt inside the leg.
Some direct trauma, like a bruise to the buttocks from a fall or pinching the nerve during an injection into the buttock area, can also trigger “sciatica.”
The most common symptoms of sciatica include: leg pain, buttocks pain, low back pain and foot or leg numbness and tingling. If the nerve compression is there for a long enough time, muscle weakness and wasting can occur. This weakness is noted during the Chiropractic examination by the Patient struggling to stand up on their tip toes leading to a limp when walking.
In the examination, your Doctor may raise your straightened leg and if the sciatic nerve is compressed, then a sharp pain can occur. If the pain occurs between 30 and 70° of elevation, this indicates a positive test for sciatica.
Testing the lower limb reflexes and skin sensation with a sharp object can give your Chiropractor clues where the is nerve damage is occuring.
The good news for patients in Belfast is that Chiropractic techniques can resolve this problem, thus helping you to avoid unnecessary surgery or the nasty side effects of prescription medication! So, check with your Doctor of Chiropractic first, before consulting the surgeon.
When low back pain strikes, we often think it’s a brand new problem. But why did coughing, twisting, or doing the hoovering cause injury this time? These are activities we normally do every day.
What is the problem this time?
The problem is caused by joint dysfunction. This is often a ligament or muscle problem that occurs by tiny micro-traumas repeated over many years, or sometimes a traumatic event such as car accidents or falls.
The ligaments can stretch or the muscles tighten, causing the joints and vertebrae in your spine to become displaced or stuck. This can irritate the delicate nerve fibers in the area. The body will usually find a way to compensate to take the pressure off that area over the next few days or weeks. The pain that accompanies this injury eventually lessens and sometimes goes away all on its own.
But has the problem really gone away?
Usually its still there in the background, because when ligaments or muscles are damaged, the repair mechanism involves the laying down of of scar tissue in the damaged area. Scar tissue is less elastic than the original tissue and this makes the joint vulnerable to re-injury. Oftentimes it impairs the normal motion of the spinal bones.
The Doctor of Chiropractic examines for this type of joint strain/sprain using a technique called motion palpation. They are looking for tenderness and swelling in the area. Sometimes x-rays are needed to see the directions the vertebrae have moved or whether they are moving at all. These specific analyses tell them the vulnerable joint directions and how the bones in the spine need to be repositioned to promote normal movement and good alignment.
When joint movements are faulty in the spine, it can lead to premature degeneration of the bones and discs and early arthritis in the area.
This may be why an everyday task such as hoovering the floor can flare up your back so easily. You may be performing the task with good posture but with faulty mechanics in the spine, a painful episode of back pain is a possible result.
Sometimes, the discs in the spine are so damaged that a simple cough or sneeze can lead to cause severe pain.
When these simple tasks seem to trip you up, there is likely an underlying problem that needs to be addressed and treated.
If you have been suffering with symptoms similar to this, please call our Belfast clinic to book an appointment with the Chiropractor.
There is a commonly held clinical belief that 90% of all low back pain episodes spontaneously self-resolve within a 60 day period.
It would appear that this commonly held “fact” may not be “factual” at all.
Possibly the most authoritative textbook of the 1970’s “Clinical Biomechanics of the Spine” was the main contributor to the 60 day self healing belief. An important comment was made on page 424 of the book.
“There are few diseases [low back pain] in which one is assured improvement of 70% of the patients 3 weeks and 90% of the patients in two months, regardless of the type of treatment employed.”
Firstly we need to ask where is this statement derived?
Reference J Dixon; Progress and Problems in Back Pain Research; Rheumatology and Rehabilitation; Volume 12, Number 4; November 1973; Pages 165-175.
Surprisingly the reference is not a scientific study at all. The reference is actually from a paper read at the Annual Meeting of the British Association for Rheumatology and Rehabilitation, London, March 1973.” (p. 165)
The first two sentences of the article are as follows:
“It is a great honor to be invited to talk to my own Medical School, but I am not noted for my contribution to back pain research nor for my startling observations into the biochemistry of the human intervertebral disc. My only contribution has been to show that patients with non-specific back pain more often do better in a rabbit-wool body belt than in a rigid spinal corset which they are more frequently prescribed.” (p. 165)
It is quite obvious, from Dixon’s own opening statement, he is not an expert on back pain, nor is he a back pain researcher of any kind.
Even though Dr. Dixon is the most often end reference of the natural history of back pain, a review of Dixon’s article finds that he actually quotes another article as well J Fry; Advisory Services Colloquia; “Back Pain and Soft Tissue Rheumatism”; Advisory Services (Clinical & General) Ltd., London; Number 1; 1972; Page 8
Dr. Fry’s contribution to the colloquium includes the following:
In an average GP practice each year 125 patients could be expected for soft tissue rheumatism or acute back pain.
“Of these 125 patients, 50 would be likely to be suffering from acute back pain and 25 from acute neck pain.”
“44% of the patients with acute low back pain lost their symptoms in less than one week and 82% in less than 4 weeks.”
Dr. Fry makes it abundantly clear that these numbers are from a retrospective review of his general practitioner practice of acute low back pain patients.
Dr. Fry provides no information regarding how he evaluated his patients and their progress or lack there of. Equally he fails to discuss how many patients he used to establish these statistics.
A more recent group of researchers, led by professor Peter Croft published in the British Medical Journal, actually took the time to evaluate the statistics on the natural history of low back pain that are frequently attributed to Dixon, and they unequivocally show Dixon’s statistics to be false.
Here is the review of the Croft Group article, the results speaks for themselves:
“Outcome of low back pain in general practice: a prospective study; British Medical Journal; May 2, 1998; Vol. 316, pp. 1356-1359; Peter R Croft, Gary J Macfarlane, Ann C Papageorgiou, Elaine Thomas, Alan J Silman”
KEY MESSAGES FROM AUTHORS:
1) It is widely believed that 90% of episodes of low back pain seen in general practice resolve within one month.
2) While 90% of subjects consulting the GP pactice with low back pain ceased to consult about the symptoms within three months, most still had substantial low back pain and related disability.
3) Only 25% of the patients who consulted about low back pain had fully recovered 12 months later.
KEY POINTS FROM THIS ARTICLE INCLUDE:
1)This prospective study of 463 patients with an acute episode of low back pain agrees with numerous other studies that indicate that approximately 90% of such patients will stop consulting their doctor about their back within three months. In this study the number was actually 92%.
2)However, this study is adamant that NOT seeing a doctor for a back problem does NOT mean that the back problem has resolved. This study showed that 75% of the patients with a new episode of low back pain have continued pain and disability a year later, even though most are not continuing to go to the doctor.
3)The belief that “90% of episodes of low back pain seen in general practice resolve within one month” is false, and based primarily upon one flawed study published in 1973 by Dixon. [As noted above, Dixon is NOT a study, and should not be referred to as such.]
4)It is generally believed that most low back pain episodes will be “short lived and that ’80-90% of attacks of low back pain recover in about six weeks, irrespective of the administration or type of treatment.'” This belief is untrue, false.
5)Many patients seeing their general practitioner for the first time with an episode of back pain will still have pain or disability 12 months later but not be consulting their doctor about it. [Very Important]
6)Low back pain should be viewed as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences.
7)90% of episodes of low back pain DO NOT end in complete recovery within a few months.
If you are part of the 92% with back pain that hasn't got better by itself, please contact our Belfast clinic to see if Chiropractic can help you.
Around 80% of people will suffer from back pain at some point in their lives. If it lasts for more than 3 months it is considered chronic back pain and can have a devastating effect on their overall quality of life.
Since back pain is usually multifactoral, there are some tips that can be used to ease the pain alongside Chiropractic treatment.
A 2017 study showed that simply taking adequate vitamin D supplementation produced significant benefits to those patients suffering with chronic lower back pain.
In the study, 68 patients with chronic lower back pain and low vitamin D levels were given an oral dose of 60,000 iu of vitamin D3 every week for 8 weeks.
The data showed that not only did the patient's vitamin D levels improve, but the participants also had a significant improvement in pain and disability throughout the course of the treament.
The authors concluded that Vitamin D supplementation can have a significant effect on the pain and disabilty of those suffering with chronic back pain.
Up to 75% of teens and adults have suboptimal levels of Vitamin D. Recent research has shown that vitamin D deficiency may be a risk factor for diseases such as cancer, depression, heart disase and diabetes.
Chiropractors frequently use supplementation and diet advice to help reduce the pain levels of our patients in Belfast.
When looking at the spine from the front it should be straight. The function and health of the spine is at its optimum when there is no lateral deviation from the front. This concept is well-reviewed by James Oschman, PhD (1):
In contrast, when the spine is viewed from the side, optimum health and function requires 3 distinct spinal curves (2):
1) Cervical Lordosis
2) Thoracic Kyphosis
3) Lumbar Lordosis
We are going to focus on the importance of cervical lordosis.
The loss of the cervical lordosis can be categorized into 3 groups:
1) Hypolordosis: is a loss of the normal curve in the neck.
2) Military: is a complete loss of the curve resulting in a straight cervical spine.
3) Kyphosis: is a complete reversal of the normal curve in the neck.
Loss of the normal neck curve is associated with a number of nerve and muscle problems. The primary problems fall into five categories:
1) Muscle strain and the consequent Myofascial Pain Syndromes.
2) Acceleration of Osteoarthritis in the neck and upper back.
3) Spinal Cord Tethering.
4) Spinal Cord Demyelination.
5) Vertebral Artery blood flow compromise.
1)Muscle strain and the consequent Myofascial Pain Syndromes.
Loss of the normal curve of the neck leads to the head being displaced forward on the spinal column. To prevent you falling onto your face, the muscles at the back of the neck and rib cage will contract to maintain balance (3). The constant muscle contraction results in pain, chronic inflammation, muscle tissue fibrosis and disability (3). The term given to this sequence of events is - "myofascial pain syndrome" (4, 5, 6).
If the head weighs 10 lbs. and the loss of neck curve pushes the head’s center of gravity forward by 3 inches, the required counter-balancing muscle contraction would be 30 lbs. (10 lbs. X 3 inches):
In these cases, although muscle therapy such as massage is helpful, it is not a long-term solution. The best solution is improvement of the neck curve, reducing lever-arm stress and allowing the counterbalancing muscles to relax.
2) Acceleration of Osteoarthritis in the neck and upper back.
Loss of normal neck curve not only pushes the head forward resulting in counterbalancing muscle contraction, it also significantly increases the load placed on the the discs and facet joints (7, 8). This starts and accelerates degenerative disc and joint disease in the cervical spine, commonly known as osteoarthritis (9, 10).
The acceleration of the osteoarthritis is most pronounced when there is a reversal of the normal neck curve. This is called a kyphosis (11, 12).
3) Spinal Cord Tethering.
With loss of cervical lordosis there is a stretching of the spinal cord (7). Chronic elongation leading to tethering of the spinal cord can result in both spinal nerve dysfunction and spinal cord vascular compromise (13, 14). These can result in both autonomic and musculoskeletal symptoms.
4) Spinal Cord Demyelination.
An important research study was published in the prestigious journal "Spine" in 2005 detailing cervical spine kyphosis and demyelination of the spinal cord (15).
This study showed that cervical spine kyphosis leads to compression of the anterior blood supply to the spinal cord, resulting in spinal cord demyelination. The demyelination was greatest at the apex of the kyphotic deformity in the neck. Blood Angiography studies showed a decrease in the density of the capillary networks at the compressed spinal cord due to the neck kyphosis.
As the kyphotic angle in the neck increased, these changes in the blood supply to the area became more marked, especially in the ventral side of the spinal cord that was directly exposed to mechanical compression.
The Anterior Spinal Artery is the main blood supply to the neurons of the anterior and lateral spinal cord.
Reversal of the normal neck curve (kyphosis) compresses the front of the spinal cord against the discs and spinal bones.
5) Vertebral Artery Blood Flow Compromise.
The vertebral artery carrys blood, nutrients and oxygen to the brainstem. There is evidence that loss of the normal cervical curve (lordosis) results in reduced blood flow from the heart, through the vertebral artery into the brain stem. This can negatively effect the normal functioning of the cranial nerves and other vital functions.
An important article on this topic was published in the journal "Medical Science Monitor" in 2016, titled: Decreased Vertebral Artery Hemodynamics in Patients with Loss of Cervical Lordosis (16).
The authors evaluated the blood flow of the vertebral arteries of patients with loss of their normal neck curve and compared it to control subjects without loss of their cervical lordosis.
30 patients with loss of cervical lordosis and 30 carefully matched controls were assessed with Doppler Ultrasonography. Vertebral artery hemodynamics were statistically compared between the patient group and control group. The cervical lordosis was assessed on X-ray using the posterior tangent method.
The authors state: “The normal cervical spine has a lordotic curve. Abnormalities of this natural curvature, such as loss of cervical lordosis or cervical kyphosis, are associated with pain, disability, and poor health-related quality of life.”
“Loss of cervical lordosis causes disrupted biomechanics, triggering a degenerative process in the cervical spine.”
“The present study revealed a significant association between loss of cervical lordosis and decreased vertebral artery hemodynamics, including diameter, flow volume, and peak systolic velocity.”
When the cervical curve is lost, the vertebral arteries “are also in danger of being stretched or compressed.”
“The results of this study indicate that loss of cervical lordosis is associated with decreased vertebral artery values in lumen diameter, flow volume, and peak systolic velocity.”
This article increases the awareness of the negative impact of loss of the normal curve in the neck. It also highlights the importance of correcting cervical lordosis.
Balmoral Spine Clinic Belfast focuses on the assessment and treatment of spinal pain, including pain and associated symptoms resulting from a loss of cervical lordosis. The most accurate assessment of spinal alignment is with X-rays.
We use a number of techniques to improve and/or restore the cervical spine lordosis. There are numerous studies in the PubMed Database indicating that Chiropractic can improve and even reverse cervical kyphosis. Our typical treatment procedures involve combinations of specific Chiropractic adjustments and extension traction exercises (17, 18, 19, 20, 21, 22, 23, 24, 25).
1) Oschman J; Energy Medicine, The Scientific Basis; Chruchill Livingstone; 2000.
2) Kapandji IA; The Physiology of the Joints; Volume Three, The Trunk and the Vertebral Column; Churchill Livingstone; 1974.
3) Cailliet R; Soft Tissue Pain and Disability; 3rd Edition; FA Davis Company; 1996.
4) Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual; New York: Williams & Wilkins, 1983.
5) Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual: THE LOWER EXTREMITIES; New York: Williams & Wilkins, 1992.
6) Simons D, Travell J; Travell & Simons’, Myofascial pain and dysfunction, the trigger point manual: Volume 1, Upper Half of Body; Baltimore: Williams & Wilkins, 1999.
7) White AA, Panjabi MM; Clinical Biomechanics of the Spine, Second Edition; Lippincott; 1990.
8) Cailliet R; Low Back Pain Syndrome, 4th edition; FA Davis Company; 1981.
9) Garstang SV, Stitik SP; Osteoarthritis; Epidemiology, Risk Factors, and Pathophysiology; American Journal of Physical Medicine and Rehabilitation; November 2006; Vol. 85, No. 11; pp. S2-S11.
10) Ruch W; Atlas of Common Subluxations of the Human Spine and Pelvis, Second Edition; Life West Press; 2014.
11) Uchida K, Nakajima H, Sato R, Yayama T, Mwaka ES, Kobayashi S, Baba H; Cervical Spondylotic Myelopathy Associated with Kyphosis or Sagittal Sigmoid Alignment: Outcome after Anterior or Posterior Decompression; Journal of Neurosurgery: Spine; November 2009; Vol. 11; pp. 521-528.
12) Grosso M, Hwang R, Mroz T, Benzel, Steinmetz M; Relationship between degree of focal kyphosis correction and neurological outcomes for patients undergoing cervical deformity correction surgery; Journal of Neurosurgery: Spine; June 18, 2013; Vol. 18; No. 6; pp. 537-544.
13) Breig A; Adverse Mechanical Tension in the Central Nervous System; Almqvist and Wiksell; 1978.
14) Wing PC, Tsang IK, Susak L, Gagnon F, Gagnon R, Potts JE; Back Pain and Spinal Changes in Microgravity; Orthopedic Clinics of North America; April 1991; Vol. 22; No. 2; pp. 255-262.
15) Shimizu K, Nakamura M, Nishikawa Y, Hijikata S, Chiba K, Toyama Y; Spinal Kyphosis Causes Demyelination and Neuronal Loss in the Spinal Cord: A New Model of Kyphotic Deformity; Spine; November 2005; Vol. 30; No. 21; pp. 2388-2392.
16) Bulut MD, Alpayci M, Şenkoy E, Bora A, Yazmalar L, Yavuz A, Gulşen I; Decreased Vertebral Artery Hemodynamics in Patients with Loss of Cervical Lordosis; Medical Science Monitor; February 15, 2016; Vol. 22; pp. 495-500
17) Leach RA. An evaluation of the effect of chiropractic manipulative therapy on hypolordosis of the cervical spine. J Manipulative Physiol Ther. 1983 Mar;6(1):17-23.
18) Harrison DD, Jackson BL, Troyanovich S, Robertson G, de George D, Barker WF. The efficacy of cervical extension-compression traction combined with diversified manipulation and drop table adjustments in the rehabilitation of cervical lordosis: a pilot study. Journal of Manipulative and Physiological Therapeutics; September 1994; Vol. 17; No. 7; pp. 454-64.
19) Troyanovich SJ, Harrison DE, Harrison DD. Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther. 1998 Jan;21(1):37-50.
20) Harrison DE, Harrison, DD, Haas JW. CBP Structural Rehabilitation of the Cervical Spine, 2002.
21) Harrison DE, Cailliet R, Harrison DD, Janik TJ, Holland B. A new 3-point bending traction method for restoring cervical lordosis and cervical manipulation: a nonrandomized clinical controlled trial. Arch Phys Med Rehabil. 2002 Apr;83(4):447-53.
22)Morningstar MW, Strauchman MN, Weeks DA. Spinal manipulation and anterior headweighting for the correction of forward head posture and cervical hypolordosis: A pilot study. J Chiropr Med. 2003 Spring;2(2):51-4.
23) Harrison DE, Harrison DD, Betz JJ, Janik TJ, Holland B, Colloca CJ, Haas JW. Increasing the cervical lordosis with chiropractic biophysics seated combined extension-compression and transverse load cervical traction with cervical manipulation: nonrandomized clinical control trial. J Manipulative Physiol Ther. 2003 Mar-Apr;26(3):139-51.
24) Ferrantelli JR, Harrison DE, Harrison DD, Stewart D. Conservative treatment of a patient with previously unresponsive whiplash-associated disorders using clinical biomechanics of posture rehabilitation methods. J Manipulative Physiol Ther. 2005 Mar-Apr;28(3):e1-8.
25)Oakley PA, Harrison DD, Harrison DE, Haas JW. Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP) publications. J Can Chiropr Assoc. 200
A Disc lesion means a disruption of the annular fibers and displacement of nuclear material in the intervertebral disc. This can lead to symptoms of inflammation and chemical irritation of the nerve or true compression of the nerve roots. Expected symptoms include pain, loss of sensation and numbness or weakness in the area of the body the effected nerve supplies
Lumbar disc lesion begins with repetitive disc strain which leads to disc herniation and ends in disc degeneration. Multiple factors contribute to the development of lumbar disc herniations. A very important systematic review and meta-analysis published in 2017 of more than 1700 patient cases determined that patients with a reduction of the normal curve in their lower back have significantly higher levels of lumbar disc herniation and lower back pain (1).
Over 90% of disc lesions occur at L4/5 or L5/S1, with the latter being most prevalent (2). The lumbar disc damage is accompanied by an inflammatory reaction capable of producing a “chemical radiculopathy”. Large disc disruption can lead to disc herniation or bulging resulting in mechanical compression of nearby nerves.
Other risk factors associated with the development of disc herniations include: a sedentary lifestyle, long periods of driving, long term smoking, previous full-term pregnancy, increased body mass index, and a tall stature (3).
Disc herniation is most likely to occur in the 40-50 years old age group and the condition is very uncommon in children (4). Approximately 35-45% of adults will experience lumbar disc lesions at some point in their lifetime and the condition is more common in men (5).
The presentation to the Chiropractor's office for lumbar disc herniations really depends on the degree of neurologic involvement. Disc lesions with no mechanical compression may present with only local discomfort and pain, or we may see pain that radiates into the buttock or upper leg.
Disc bulges with mechanical compression of a nerve can present with all of the above symptoms but also with decreased muscle strength and abnormal reflexes. Referred pain into the limbs is described by the patient as sharp and sometimes accompanied with pins/needles or altered sensation. As a Chiropractor our job is to rule out "Red Flags" such as Cauda Equina where the patient will present with numbness or altered sensation in the saddle area, they may also report loss of bowel or bladder function and this is deemed a medical emergency situation and the patient will likely require immediate surgery.
Disc herniation with limb pain can be successfully managed via conservative Chiropractic treatment (6). In fact, the majority of disc herniations will reduce over time without the need of surgery. (7,8) . The goal of conservative Chiropractic management is to centralize symptoms, reduce pain and inflammation in the area, decrease mechanical compression of the nerve and improve functional core stability.
McMorland reported that the main technique carried out by the Chiropractor produced results equal to surgical decompression in 60% of lumbar disc lesion patients who had failed earlier medical management. He concluded: “Patients with symptomatic lumbar disc herniation should consider spinal manipulation before surgery" (9). An other study of 148 patients demonstrated significant and lasting improvement in all outcome measures (with no adverse events) when spinal manipulation was applied to the level of the disc lesion (10). Chiropractic patients with disc herniation who undergo spinal manipulation at the level of disc involvement demonstrate a significant decrease in radicular symptoms (pain in the limbs) (11).
A study of 1271 lower back pain patients determined that patients with related leg pain and signs of nerve root involvement will have a worse prognosis than patients with low back pain only. Chiropractic clinical outcomes with low back pain are very impressive.
After two weeks of treatment, patients with local lower back pain only - 77% had improved.
Patients with lower back pain and pain above the knee - 72 % improved after just 2 weeks.
Average outcomes for Chiropractic patients, regardless of the location of pain were significantly better than those who sought treatment from their GP’s at 2 weeks (74% improved vs 36% improved), 3 months (82% improved vs. 60% improved), and 12 months (73% improved vs. 54% improved). (12)
1.The relationships between low back pain and lumbar lordosis: a systematic review and meta-analysis. Chun, Se-Woong et al. The Spine Journal , Volume 17 , Issue 8 , 1180 - 1191
2. Frymoyer JW. Back pain and sciatica. N Engl J Med 1988;318: 291-300.
3. Nachemson AL: Prevention of chronic back pain. The orthopaedic challenge for the 80's. Bull Hosp Jt Dis Orthop Inst 44:1-15, 1984.
4. Hoffman HJ: Childhood and adolescent lumbar pain: differential diagnosis and management. Clin Neurosurg 1980; 27:553-576.
5. Hurwitz EL, Shekelle P. Epidemiology of low back syndromes. In: Morris CE, editor. Low back syndromes: integrated clinical management. New York: McGraw-Hill; 2006. p. 83-118.
6. Saal JA, Saal JS: Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy an outcome study. Spine 1989; 14:431-436
7. Chiu CC, Chuang TY, Chang KH, Wu CH, Lin PW, Hsu WY. The probability of spontaneous regression of lumbar herniated disc: a systematic review. Clin Rehabil. 2015 Feb;29(2):184-95.
8. Zhong M, Liu JT, Jiang H, Mo W, Yu PF, Li XC, Xue RR. Incidence of Spontaneous Resorption of Lumbar Disc Herniation: A Meta-Analysis. Pain Physician. 2017;20(1):E45–E52.
9. McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ.
Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study . J Manipulative Physiol Ther. 2010 Oct;33(8):576-84. doi: 10.1016/j.jmpt.2010.08.013
10. Serafin Leemann, Cynthia K. Peterson, Christof Schmid, Bernard Anklin, and B. Kim Humphreys. Outcomes Of Acute And Chronic Patients With Magnetic Resonance Imaging–confirmed Symptomatic Lumbar Disc Herniations Receiving High-velocity, Low-amplitude, Spinal Manipulative Therapy: A Prospective Observational Cohort Study With One-year Follow-up. JMPT 01/2014; DOI:10.1016/j.jmpt.2013.12.011.
11. Ehrler M, Peterson C Leemann S et al. Symptomatic, MRI Confirmed, Lumbar Disc Herniations: A Comparison of Outcomes Depending on the Type and Anatomical Axial Location of the Hernia in Patients Treated With High-Velocity, Low-Amplitude Spinal Manipulation. JMPT Mar-April 2016, Volume 39, Issue 3, Pages 192–199.
12. Hartvigsen L. et al. Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain. BMC Musculoskeletal Disorders 2017, 18:133
The "Pain Gate Theory" has been accepted as a viable explanation for the benefits of Chiropractic treatment.
Canadian orthopedic surgeon WH Kirkaldy-Willis, MD (1)notes :
“Spinal manipulation is essentially an assisted passive motion applied to the spinal joints.”
Since 1965, Melzack and Wall's proposed Pain Gate Theory has “withstood rigorous scientific scrutiny.”
“The transmission of pain can be impeded by increased proprioceptive input.” Pain is increased by “lack of proprioceptive input.” This is why it is so important to regain early movement in joints after an injury.
The facet joints in the spine are densely populated with mechanoreceptors. How Chiropractic works is by increasing proprioceptive input in the form of spinal adjustments to decrease the central transmission of pain from adjacent spinal structures by closing the "Pain Gate".
By the Chiropractor applying a stretch into the facet joint capsule, the aim is to fire capsular mechanoreceptors which will “inhibit facilitated motoneuron pools” which are responsible for the muscle spasms that commonly accompany low back pain.
Mechanoreceptors are considered the most important source of the “non-nociceptive” afferents that control pain. Therefore improving their function closes the pain gate and in turn reduces pain.
The increased muscle spasm that often accompanies spinal pain also reduces spinal motion and results in opening the pain gate and in turn increasing the patients pain.
Our muscles become a key player in chronic spinal pain conditions because of overlapping feedback loops:
1) Pain leads to increased muscle tone.
2) Increased muscle tone leads to more inflammation and more pain.
3) An increase in muscle tone reduces joint range of motion.
4) Reduced range of motion leads to reduced mechanoreception.
5) Reduced joint mechanoreception opens the pain gate.
6) The “open” pain gate leads to more pain and further increased muscle tone (again, a feedback loop).
This feedback loop mechanism was eloquently reviewed by Yale’s Manohar Panjabi, PhD (2):
The theoretical basis for Panjabi’s model was based on the animal studies carried out by Aage Indhal, MD, and colleagues from Norway (3). The studies clearly showed the relationship between spine pain and contraction of the segmental muscles, leading to reduced movement of that region of the spine.
Indahl was also able to show that by stimulating the mechanoreceptors of the facet joint they could inhibit the spinal cord reflex to the spinal muscles causing the spasm and also decrease pain.
Dr. Indahl’s experiments and Dr. Panjabi’s models are perfect matches to how Chiropractic spinal adjusting works.
Raymond Brodeur is a Chiropractor and Engineer working at Michigan State University (4). Dr. Brodeur’s basic premise is that the cavitation ( popping noise) associated with the audible adjusting of a spinal segment has sufficient speed to fire off high-threshold mechanoreceptors,decreasing muscle spasm and improving joint motion.
The primary research by Orthopedic Surgeon WH Kirkaldy-Willis, MD was clearly able to show that Chiropractic spinal adjusting was capable of decreasing both muscle spasm and pain (1). Dr. Kirkaldy-Willis used 283 patients with chronic, severe, treatment resistant low back pain and documented that Chiropractic spinal adjusting was able to fix the condition in 81% of the patients.
Dr. Kirkaldy-Willis’ explanation for the observed improvement in clinical status was the firing of facet capsule mechanoreceptors, which decreases muscle spasm and closes the pain gate.
1) Kirkaldy-Willis WH; Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985, Vol. 31, pp. 535-540.
2) Panjabi MM; A hypothesis of chronic back pain: ligament subfailure injuries lead to muscle control dysfunction; Eur Spine J. 2006 May;15(5):668-76.
3) Indahl A, Kaigle A, Reikerås O, Holm S; Electromyographic response of the porcine multifidus musculature after nerve stimulation; Spine (Phila Pa 1976). 1995 Dec 15;20(24):2652-8.
4) Brodeur R; The audible release associated with joint manipulation; J Manipulative Physiol Ther. 1995 Mar-Apr;18(3):155-64.
Leg length inequality and a pelivis that is not level is a common cause of low back pain.
The biomechanics of the lower back is closely linked to the biomechanics of the foot, leg, and pelvis.
Doctors may be tempted to only focus on the back with their back pain patients, however oftentimes the stresses in these tissues are caused by biomechanical problems in the feet, knees or pelvis. Failure to address biomechanical problems in these areas often results in poor clinical outcomes and the patient fearing the problem will never get better.
Successful management of low back issues requires full assessment of biomechanical problems of the lower extremities and pelvis because they are linked through the kinetic chain effecting posture and ambulation.
The first large research study into leg length issues was carried out over 70 years ago
In 1946, Lieutenant Colonel Weaver A. Rush and Captain Howard A. Steiner of the X-ray Department of the Regional Station Hospital of Fort Leonard Wood, Missouri, took standing lumbosacral X-rays on 1,000 soldiers for the specific purpose of measuring differences in their leg lengths and to determine if inequality of leg length was a factor in the incidence of back pain. Their research was published in the American Journal of Roentgenology and Radium Therapy and is titled 1): A Study of Lower Extremity Length Inequality.
23% of the soldiers had legs of equal length.
77% of the soldiers had unequal length of their legs.
No difference was noticed in limb shortness between the left and right legs and the average shortening was slightly more than 7 mm.
Importantly, the authors noted that the short leg was associated with a tilt of the pelvis and a scoliosis.
The Authors noted: “It was a general consistent observation that the degree of scoliosis was proportionate to the degree of pelvic tilt. An individual who has a shortened leg will have to compensate completely if he intends to hold the upper portion of his body erect or in the midsagittal plane.”
They also noted:
"Leg length differences exceeding 5 mm were associated with the greatest low back pain or disability, and therefore 5 mm is labeled as being a “marked difference.”
“For this reason, it is our opinion that the existence of such a condition [a short leg exceeding 5 mm] is significant from the standpoint of symptomatology and disability.”
Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual:
In these books, Drs. Travell and Simons discuss difficult cases caused by structural deficiencies, the most common of which were:
A difference in the length of the lower limbs.
A long second metatarsal or a short first metatarsal.
It has been documented since 1946 that around three quarters of the population have unequal leg lengths and that about a third of people have leg length differences that can perpetuate trigger points (2). As a general rule, the sacrum is lower on the side of the short leg. The spine initially tilts towards the short leg, then compensates back to the midline as a consequence of chronic contraction of the quadratus lumborum muscle. Dr. Travell states the resulting trigger points in the quadratus lumborum muscle are a very common but frequently overlooked cause of chronic low back pain (3).
Dr. Travell stated that the solution was a heel lift for the short leg, these are commonly applied using orthotics in modern clinics
This concept of a pronated foot lowering the pelvis on the same side, altering lumbar spine biomechanics has been confirmed in more recent publications, including sports medicine reference books authored by podiatrists (4).
Another cause for the increased occurence of low back pain in individuals with an anatomical short leg is that it can also cause counter-rotational stress at the L5-S1 intervertebral disc. This phenomenon was best described by Ora Friberg, MD, from Finland. Dr. Friberg published his findings in 1987 in the journal Clinical Biomechanics, titled (5): The Statics of Postural Pelvic Tilt Scoliosis;A Radiographic Study on 288 Consecutive Chronic LBP Patients
The intervertebral disc has two components. The center of the disc is called the Nucleus Pulposus, or simply nucleus. The nucleus is mostly water and functions as a ball bearing, allowing the vertebrae to bend and twist.
In this study by Friberg, standing X-rays of the pelvis and lumbar spine in 288 consecutive patients with chronic low back pain and in 366 asymptomatic controls were taken. The findings showed that 73% of the patients assessed had more than 5mm difference in leg length. The incidence of leg length inequality in lower back pain patients was twice as much as the patients with no pain (controls).
Friberg emphasized the counter-rotational stresses on the L5-S1 disc: "These “significant” counter-rotational stresses primarily affect the L5-S1 intervertebral disc. The consequences of these counter-rotational stresses at L5 are accelerated disc degeneration and degradation, back pain and sciatica."
A recent (2016) study pertaining to the biomechanical consequences of an anatomical short leg was published in the Journal of Craniovertebral Junction Spine and titled (6): Inequality in Leg Length is Important for the understanding of the pathophysiology of Lumbar Disc Herniation.
The researchers studied 39 subjects with leg length inequality and low back pain and 43 controls to note the differences in occurrence of disc herniation between between the two groups. They found that leg length inequality causes spinal joint load assymetry, accelerating disc degeneration and disc herniation. They also suggested that poor low back disc surgical outcomes may be linked to the abnormal spinal loads caused by leg length inequality, They state:
“Inequality in leg length may lead to abnormal transmission of load across the endplates leading degeneration of the lumbar spine and the disc space.”
“Patients with chronic lower back pain have minor balance defects. Inequality in leg length is important for understanding of reasons behind lumbar disc degeneration and herniation.”
This year (2017), a very important article was published in the Archives of Physical Medicine and Rehabilitation, titled (7): Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial.
The aim of this study was to investigate how shoe orthotics with or without Chiropractic treatment for chronic low back pain compared to no treatment at all. This was a randomized controlled trial (three groups) that involved 225 adults with symptomatic low back pain of 3 months or longer:
Group 1:"Orthotics Group" received custom-made shoe orthotics only.
Group 2: "Plus Group" received custom-made orthotics plus Chiropractic treatment.
Group 3: "Wait Group" received no care.
Both pain levels and disability were assessed at 6 weeks and 12 weeks, and then after an additional 3, 6, and 12 months. These authors note:
“The best results were in the Orthotics Plus Chiropractic group in which 70% had a decrease in pain and 56% a decrease in disability of 30% or more compared to baseline.”
“This large-scale clinical trial show that LBP and disability were significantly improved after six weeks of orthotics care compared to a wait-list control, and that the addition of chiropractic care with the orthotics demonstrated a significant improvement in the disability scores compared to orthotics alone.”
“Foot and leg length dysfunction must not be overlooked as a contributing factor in treating lower back pain.”
Rush WA, Steiner HA; A Study of Lower Extremity Length Inequality; American Journal of Roentgenology and Radium Therapy; Vol. 51; No. 5; November 1946; pp. 616-623.
Travell J, Simons D; Myofascial pain and dysfunction, the trigger point manual: THE LOWER EXTREMITIES; New York: Williams & Wilkins, 1992.
Simons D, Travell J; Travell & Simons’, Myofascial pain and dysfunction, the trigger point manual: Volume 1, Upper Half of Body; Baltimore: Williams & Wilkins, 1999.
Subotnick SI; Sports Medicine of the Lower Extremity; Churchill Livingstone; 1989.
Friberg O; The statics of postural pelvic tilt scoliosis; a radiographic study on 288 consecutive chronic LBP patients; Clinical Biomechanics; Vol. 2; No. 4; November 1987; pp. 211-219.
Balik SM, Kanat A, Erkut A, Ozdemir B, Batcik OE; Inequality in Leg Length is Important for the Understanding of the Pathophysiology of Lumbar Disc Herniation; Journal of Craniovertebral Junction Spine April-June 2016; Vol. 7; No. 2; pp. 87-90.
Cambron JA, Dexheimer JM, Duarte M, Freels S; Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial; Archives of Physical Medicine and Rehabilitation; April 29, 2017. [Epub]
A recent Danish study of 1271 patients with lower back pain concluded that patients with lower back and leg pain will have a worse prognosis than patients with lower back pain alone.
The outcomes of the first 2 weeks of Chiropractic treatment varied depending on how far the pain had initially spread down the leg.
Lower back pain only - (77% of patients improved after 2 weeks of Chiropractic)
Lower back pain + pain above the knee - (72 % improved after 2 weeks of Chiropractic)
Lower back pain + pain below the knee - (61% improved after 2 weeks of Chiropractic)
Lower back pain + positive nerve tension test (SLR) or abnormal neuro findings - (40% improved after 2 weeks of Chiropractic)
As expected, average outcomes for Chiropractic patients, regardless of pain location were significantly better than those of patients who were only under the care of their GP’s.
At 2 weeks (74% improved with Chiropractic vs 36% improved with GP).
At 3 months (82% improved with Chiropractic vs. 60% improved with GP).
Hartvigsen L, Hestbaek L, Lebouef-Yde C, Vach W, Kongsted A. Leg pain location and neurological signs relate to outcomes in primary care patients with low back pain. BMC Musculoskeletal Disorders. 2017;18:133. doi:10.1186/s12891-017-1495-3.
The medical definition of a migraine headache is (1):
The headache must last between 4 to 72 hours.
The headache is associated with either nausea / vomiting / phonophobia / photophobia.
The headache must be characterized by two of the following four symptoms: throbbing pulsile quality; unilateral location; moderate or severe degree of pain; made worse by physical activity.
A diagnosis of Migraine is formed when these characteristics are present:
-Pain involves half of the head.
-An aura is present.
-Associated gastro-intestinal symptoms.
-There is phonophobia and or photophobia.
-Pain is aggravated by the Valsalva maneuver and or by the "head-low position".
-The migraines can be triggered by: The menstrual cycle; Oversleeping; Fasting; Alcohol; Tyramine-containing foods (meats that are pickled/aged/smoked/fermented/most pork; chocolate; and fermented foods.
-Migraine relief occurs with sleep.
Nikoli Bogduk, MD, PhD, is one of the World's leading Musculoskeletal researchers.
Dr. Bogduk’s expertise in clinical anatomy includes headaches. A literature search using the words “Bogduk + Headache” finds 25 separate citations. One of his most important contributions to the study of understanding headaches appeared in the scientific journal Biomedicine and Pharmacotherapy. The article is titled (2): "Anatomy and Physiology of Headache".
In this review, Bogduk notes that “all headaches are mediated by the trigeminocervical nucleus.”
This means that all headaches, including migraines, synapse in the upper aspect of the neck, in an area called the trigeminocervical nucleus. The trigeminocervical nucleus is housed in the brainstem and the upper cervical spinal cord.
Upper cervical spine afferents to a second-order neuron that also receives trigeminal input may be a source of the electrical signal that is interpreted as headache in the brain, including migraine headache. Therefore structures that are innervated by C1/C2/C3, can cause headaches including migraine. Irritation or inflammation of structures supplied by C1/C2/C3 can all cause headaches. Such structures include:
The Dura mater.
Anterior and posterior upper cervical and cervical occipital muscles.
C1/2/3 cervical joints.
Vertebral and Carotid arteries.
Transverse and Alar ligaments.
The Trapezius muscle.
The Sternocleidomastoid muscle.
In 2017, researchers from Akershus University Hospital, Oslo, Norway, and the Department of Chiropractic, Macquarie University, NSW, Australia, published a study in the journal Musculoskeletal Science and Practice titled (3):
Adverse Events in a Chiropractic Spinal Manipulative Therapy: A Single-blinded, Placebo, Randomized Controlled Trial for Migraineurs
The authors note that migraines are a common challenge, and pharmacological management is often the first treatment of choice. However these drugs can have serious and undesirable side effects. In contrast, manual-therapy carried out by Chiropractors appears to have a similar effect as common drugs on migraine frequency, migraine duration, and migraine intensity.
70 migrainers were randomized to chiropractic manipulation (Gonstead full-spine adjusting) or a placebo, with 12 intervention sessions over three months. The subjects in this study were randomly placed into three groups:
An active spinal manipulation group, using Gonstead technique: “Active treatment consisted of chiropractic spinal manipulation using the Gonstead method.
A placebo manipulation group, receiving sham manipulation: “The placebo intervention consisted of sham manipulation, i.e., a broad non-specific contact approach via a low-velocity, low-amplitude sham push manoeuvre in a non-intentional and nontherapeutic directional line.
A control group, using usual pharmacological management: “The control group continued their usual pharmacological management without receiving manual intervention.”
The participants were interviewed and physically assessed by a Chiropractor, “including meticulous investigation of the spinal column.” They also received a full spine X-rays. The subjects attended treatments over 12 weeks with follow-up at 3, 6 and 12 months post-treatment. The authors concluded:
This study “showed significant differences between the Chiropractic spinal manipulation group and the control group [drug group] at all post-treatment time points.”
“These findings are in accordance with the World Health Organization guidelines on basic training and safety in chiropractic spinal manipulation, which is considered to be an efficient and safe treatment modality (WHO, 2005).” (4)
Non-pharmacological management of migraine has the advantage of having mild and transient adverse events, “whereas pharmacological adverse events tend to be continuous.”
“Chiropractic spinal manipulation applying the Gonstead technique appears to be safe for the management of migraine headache and presents few mild and transient adverse events.”
The group being treated by the chiropractor had the best long-term results.
These studies explain what essentially every chiropractor has observed:
Improvement of the mechanical function of the upper cervical spine with spinal manipulation is an effective and safe treatment for patients suffering from migraine headache.
The presented data here suggests that manipulation actually addresses the cause of the migraine headache; in contrast, it appears that taking drugs is nothing more than temporary pain control with no improvement to the causative pathophysiology of migraine headache.
1) Jones HR, MD; Netter’s Neurology; 2005.
2) Bogduk N; Anatomy and Physiology of Headache; Biomedicine and Pharmacotherapy; 1995, Vol. 49, No. 10, 435-445.
3) Chaibi A, Benth JS, Tuchin PJ, Russell MB; Adverse Events in a Chiropractic Spinal Manipulative Therapy Single-blinded, Placebo, Randomized Controlled Trial for Migraineurs; Musculoskeletal Science and Practice ; March 2017; Vol. 29; pp. 66-71.
4) WHO, 2005. Guidelines on Basic Training and Safety in Chiropractic. World Health Organization, Switzerland.