Low Back Pain & Patient Education

Patient education is a very important aspect of caring for our patients. In fact, it can be one of the most important aspects of care. For example, when patients present with a brand new injury and pain levels are off the map, it’s quite common for that acute suffering patient to inappropriately think that, “I’m going to die… this hurts so much!” Hence, one of the very first things we do as chiropractors is to determine what structures are generating the pain so we can tell you! Once you have an understanding of where the pain is coming from and why it hurts so bad, then you can be reassured that it’s not life threatening or dangerous. Also, at this acute point of time, the patient often unknowingly puts heat on the back, often for hours. This is the WORST thing you can do as the area is already swollen and putting heat on a swollen area draws more blood and fluids into the area. It’s literally like throwing gas on a fire. So, receiving proper information from us such as, put ice on the area for 15-20 minutes on and off several times in a row to “PUMP” the swelling out of the area will make complete sense. Also, did you know that 2/3rds of our body’s weight is above the waist? That means, when a 150# person bends over, they are “lifting” 100#! That’s one of several reasons why bending over can be so dangerous. To “fix” that, squat by bending the knees keeping the back straight and keep objects that you might be lifting close to your body as that weight literally weighs 10x more when your arms are straight and you’re lifting. When you can’t squat and have to bend over, bend the knees, arch your back (literally “stick your butt out”), and bend over at your hip joints – DON’T use your back. You’ll need to practice that one a few times before it’s fully understood. As your back pain improves, we will review these important self-help approaches and add new “tricks of the trade” like certain stretches, some strengthening and perhaps some balance exercises. Did you know that your thigh muscles shrink just by sleeping overnight? It’s true! When you wake up in the morning, your thigh muscles are smaller than when you went to bed. Well, this same muscle shrinkage (technically called “atrophy”) occurs in the lower back and hips, so strengthening exercises are REALLY IMPORTANT! Just think, if your muscles shrink overnight just from laying in bed, what about when you might have been told to use bed rest for several days or more? There potentially is a lot of muscle shrinkage and weakness that can occur in a relatively short amount of time and therefore, strengthening exercises also need to be taught in order to regain your strength so you can more safely do your activities. Now what about back pain prevention? What methods to you think will help us NOT get low back pain? That’s right – managing weight! If your BMI (body mass index or, the ratio between your height and weight) is >25, you need to trim down a bit (or more). Go on line and SEARCH BMI, and pick one of many “BMI Calculators” to figure out your BMI. So, what do chiropractors know about weight loss? Did you know the chiropractic college curriculum includes more nutritional courses than most medical schools? We will help you find a way to lose weight – whether its calorie restriction, a special diet like no/low salt, gluten-free, or a diabetes-specific diet. Another prevention trick for the low back (actually, whole body!) is to STAY FIT! Make aerobic exercise and even a light weight lifting program part or your daily ritual. Other methods help too, so come in and let us guide you in this journey to better health! We realize you have a choice in who you choose to provide your healthcare services. If you, a friend or family member requires care for low back pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.

Nawlin's New Year 2012

Well it's Mardi Gras time in Nawlins! Which is when most people round here begin their New Year's Resolutions! After the King Cake and the Parades we finally have enough motivation to begin our official New Year's Resolutions of shedding a few pounds or dropping an indulgence for a few weeks! So, here we go, another 40 days without sweets or perhaps a new workout routine, whatever it is you do to start the "New Year" off right, I just wanted to invite you to join us! Whether you've been with us before or your just learning about us, come on board with our Wellness Strategies to get you to your wellness goals! We have IDEAL Protein, Bio-identical Hormone replacement, Far-infrared Sauna, Zerona Lipo-Laser, Endermologie & Nutritional Counseling from the Hottest Wellness Doc in town! (of course I'm a lil' bias...I'm married to her!) Anyway, Dr. Hannan is awesome at helping you set and reach your wellness goals through state of the art wellness technologies and techniques which help speed up the process to getting to optimal health & wellness...so, Happy New Year's Nawlins ! Check out our website @ hannanwellness.com for more info or just drop by to pick up some info @ 101 Clearview Pkwy. @ Airline Hwy. in Metairie, La.,
Have a great month!

Low Back Pain: Spondylolisthesis

Low back pain can arise from many conditions, one of which is a mouthful: spondylolisthesis. The term was coined in 1854 from the Greek words, “spondylo” for vertebrae and “olisthesis” for slip. These “slips” most commonly occur in the low back, 90% at L5 and 9% at L4. According to www.spinehealth.com and others, the most common type of spondylolisthesis is called “isthmic spondylolisthesis,” which is a condition that includes a defect in the back part of the vertebra in an area called the pars interarticularis, which is the part of the vertebra that connects the front half (vertebral body) to the back half (the posterior arch). This can occur on one, or both sides, with or without a slip or shift forwards, which is then called spondylolysis. In “isthmic spondylolisthesis,” the incidence rate is about 5-7% of the general population favoring men over women 3:1. Debate continues as to whether this occurs as a result genetic predisposition verses environmental or acquired at some point early in life as noted by the increased incidence in populations such as Eskimos (30-50%), where they traditionally carry their young in papooses, vertically loading their lower spine at a very young age. However, isthmic spondylolisthesis can occur at anytime in life if a significant backward bending force occurs resulting in a fracture but reportedly, occurs most frequently between ages 6 and 16 years old.

Often, traumatic isthmic spondylolisthesis occurs during the adolescent years and in fact, is the most common cause of low back pain at this stage of life. Sports most commonly resulting in spondylolisthesis include gymnastics, football (lineman), weightlifting (from squats or dead lifts) and diving (from over arching the back). Excessive backward bending is the force that overloads the back of the vertebra resulting in the fracture sometimes referred to as a stress fracture, which is a fracture that occurs as a result of repetitive overloading over time, usually weeks to months.

If the spondylolisthesis lesions do not heal either by cartilage or by bone replacement, the front half of the vertebra can slip or slide forwards and become unstable. Fortunately, most of these heal and become stable and don’t progress. The diagnosis is a simple x-ray, but to determine the degree of stability, “stress x-rays” or x-rays taken at endpoints of bending over and backwards are needed. Sometimes, a bone scan is needed to determine if it’s a new injury verses an old isthmic spondylolisthesis.

Another very common type is called degenerative spondylolisthesis and occurs in 30% of Caucasian and 60% of African-American woman (3:1 women to men). This usually occurs at L4 and is more prevalent in aging females. It is sometimes referred to as “pseudospondylolisthesis” as it does not include defects in the posterior arch but rather, results from a degeneration of the disk and facet joints. As the disk space narrows, the vertebra slides forwards. The problem here is that the spinal canal, where the spinal cord travels, gets crimped or distorted by the forward sliding vertebra and causes compression of the spinal nerve root(s), resulting pain and/or numbness in one or both legs. The good news about spondylolisthesis is that non-surgical approaches, like spinal manipulation in particular, work well and chiropractic is a logical treatment approach!

Low Back Pain: Where Is My Pain Coming From?

Low back pain can emanate from many anatomical locations (as well as a combination of locations), which always makes it interesting when a patient asks, “…doc, where in my back is my pain coming from?” In context of an office visit, we take an accurate history and perform our physical exam to try to reproduce symptoms to give us clues as to what tissue(s) may be the primary pain generators. In spite of our strong intent to be accurate, did you know, regardless of the doctor type, there is only about a 45% accuracy rate when making a low back pain diagnosis? This is partially because there are many tissues that can be damaged or injured that are innervated by the same nerve fibers and hence, clinically they look very similar to each other. In order to improve this rather sad statistic, in 1995 the Quebec Task Force published research reporting that accuracy could be improved to over 90% if we utilize a classification approach where low back conditions are divided into 1 of 3 broad categories:

1. Red flags – These include dangerous conditions such as cancer, infection, fracture, cauda equina syndrome (which is a severe neurological condition where bowel and bladder function is impaired). These conditions generally require emergency care due to the life threatening and/or surgical potential.
2. Mechanical back pain – These diagnoses include facet syndromes, ligament and joint capsule sprains, muscle strains, degenerative joint disease (also called osteoarthritis), and spondylolisthesis.
3. Nerve Root compression – These conditions include pinching of the nerve roots, most frequently from herniated disks. This category can include spinal stenosis (SS) or, combinations of both, but if severe enough where the spinal cord is compromised (more commonly in the neck), SS might then be placed in the 1st of the 3 categories described above.

The most common category is mechanical back pain of which “facet syndrome” is the most common condition. This is the classic patient who over did it (“The Weekend Warrior”) and can hardly get out of bed the next day. These conditions can include tearing or stretching of the capsule surrounding the facet joint due to performing too many bending, lifting, or twisting related activities. The back pain is usually localized to the area of injury but can radiate down into the buttocks or back of the thigh and can be mild to very severe.

Low Back Pain and Scoliosis

Scoliosis is a term used to describe a curvature of the spine that is not “normal.” The normal curves of the spine include an inward curve in the low back and neck and an outward curve in the mid-back when looking at the person from the side (“sagittal plane”). However, there should NOT be any curves when looking at a person from the front or back (the frontal plane), the spine should be straight. When there is a curve in the frontal plane, this is called scoliosis and it’s usually either a singe curve, shaped like the letter “C” or, a double (or more) curve, shaped like the letter “S”. Though there is a diagnostic code specific for scoliosis, it is not in itself a disease or a diagnosis and frequently, there are no or at worst, minimal symptoms associated with it. For this reason, most of the time, scoliosis is not noticed until the curve progresses significantly and a friend or family member makes a comment about it or a school screening picks it up.

The most common spinal location for scoliosis to develop is in the middle to upper back (called the thoracic spine) but it can also be located at the junction between the mid back and low back, as well as in the low back only or more rarely, in the neck only. Since there are rarely symptoms associated with scoliosis, the way it’s found is by observing one or more of the following:

• One shoulder is higher than the other
• One shoulder blade sticks out more than the other
• One side of the rib cage appears higher than the other (called a “rib hump”)
• One hip appears higher or more prominent than the other
• The waist appears uneven
• The body tilts to one side
• One leg may appear or actually be shorter than the other

The use of x-ray usually is appropriate to confirm the diagnosis, to measure the amount of curve, which can then be used for future comparison, and to rule out a possible unusual cause of scoliosis. Rarely is an MRI required – only in cases where neurological signs and symptoms exist and, in younger children (ages 8-11 years old) as scoliosis almost always occurs during the puberty timeframe when hormonal systems are kicking in, such as ages 12-14. When scoliosis occurs at ages less than 11, when there are neurological changes (reflex, muscle strength and/or sensory functions), and/or when the mid-back/thoracic curve bends to the left (as it almost always curves to the right), an MRI is appropriate to rule out spinal cord pressure.

The decision to treat or not to treat is dependent on 2 factors: 1) The “skeletal maturity of the patient” (how much growing is left for the person) and, 2) The degree of the curve. In general, the bigger the curve and the younger the patient, the greater the chance for curve progression or worsening. With that said, curves less 10° reportedly don’t require treatment but over 20° should be watched at 4-6 month intervals. If a curve progresses >5° and/or when the curve is >30° in an adolescent, the person should be treated - most doctors would utilize a back brace. Chiropractors can offer additional care by applying spinal adjustments, reducing leg length deficiencies when a compensatory lumbar/low back curve is present and by offering scoliosis-specific exercises.

Low Back Pain: An Unusual Cause?

There are many causes of low back pain (LBP). Most of us can think of the time we bent over to lift a child, the heavy tongue of a trailer, a 5-gallon pail of water, or maybe simply sneezed too hard and threw out our back. These causes are common and most often associated with LBP. But, one unusual cause of LBP (not so unusual once you know about it) involves Vitamin D deficiency. Yes, you heard me – a VITAMIN DEFICIENCY!

One study reported on a 360 patient (90% women, 10% men) group being treated at spinal and internal medicine clinics over a 6-year time frame for LBP of 6 months or greater with no obvious cause. Doctors tested these patients for blood levels of vitamin D (25-hydroxy vitamin D), as well as calcium and alkaline phosphatase (an enzyme found in bone). Then, they administered Vitamin D supplements and the same tests were repeated. Their results are VERY INTERESTING! The findings showed 83% of the group studied (299 patients) had abnormally low levels of vitamin D before supplementation and after treatment of ONLY vitamin D, clinical improvement was seen in ALL the groups that had low vitamin D levels and in 95% of all 360 patients! THAT’S AMAZING! They conclude “Vitamin D deficiency is a major contributor to chronic low back pain,” and recommend screening for vitamin D deficiency and treatment with supplements which they say, “…should be mandatory...,” especially in areas that are “endemic” for vitamin D deficiency. They also conclude that bone softening diseases like osteomalacia may occur as a result of vitamin D deficiency, while many other studies have linked vitamin D deficiency with osteoporosis.

Another question then arises, what geographic regions are most susceptible to low sunlight and hence, vitamin D deficiency? One study showed that during the 8 months centered around summer in the US (March-October), for all locations from the southern tip of Texas to just south of Portland, OR, no difference was found in the vitamin D levels. But, in the winter months (November-February), a significant difference was seen where as latitude increased northward, the amount of vitamin D decreased “dramatically.” However, in lower latitudes (<25 degrees), no difference was found between summer vs. winter months. What about sun block? Does using it reduce vitamin D absorption from the sun? The answer is, YES. On “The Peoples Pharmacy” website (http://www.peoplespharmacy.com/2011/06/13/sunscreens-block-vitamin-d/), it was reported that the typical dose of vitamin D of 400 IU “…is probably inadequate to overcome a deficiency.” They recommend 10-15 minutes of time in the sun without sunscreen a few times a week or a higher dose of vitamin D3 (“…closer to 2000 IU of vitamin D”).

There are MANY other benefits – not just in terms of LBP – from taking vitamin D that have good scientific support. In fact, a PubMed search for “benefits of vitamin D” resulted in 554 studies, some of which included conditions such as, HIV, heart conditions (many), chronic illness in the elderly, osteoporosis, cancers (colorectal, prostate, breast and others), kidney disease, autoimmune diseases (celiac disease, MS, rheumatoid arthritis, many others), types I & II diabetes, and more! You get the picture, I’m sure.

We realize you have a choice in who you choose to provide your healthcare services. If you, a friend or family member requires care for low back pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.

Happy Thanksgiving to All

Happy Thanksgiving to all of our wellness family & friends! Thank you for your trust in our care and your faithfulness to our clinic! We appreciate you all and pray you have a wonderful Thanksgiving with your families & friends!

Be Blessed, Dr. Debbi & Daron Hannan