Monthly Archives: September 2013

Sacro-iliac pain and Chiropractic

I took the following from a chiropractic message board. It is copied and pasted. From one of my colleagues:

Yesterday a male patient in my office mad as a hornet. About 6 months ago, I
told him he had a SI subluxation. Needed Chiro care, no he went to the “EXPERT”
Ortho surgeon. 6 weeks of PT, hip replacement and guess what? Still has sharp
pain at the PSIS!Surgeon says nothing else to do, he needs counseling on how to
live with chronic pain. He also has a script for 2 vicodin pills/24hrs.

I love the scientific approach. (High profit) Beats a dumb non scientific
Chiropractor. (Very little profit in Chiropractic).

Evon Barvinchack, D.C.

Thanks Dr. Barvinchack for this post. I didn’t ask to repost it, but I’m sure you won’t mind.

Steven D. Lehmann D.C.

A question on exercise from a patient

A patient posed this question to me today: Better to go to the chiro after a workout or before?

My answer was this: I would suggest before…….why?

Because joints that are locked are also called inhibited. This joint inhibition also affects muscles by making them weaker and usually tighter (think about it, if you’re tight/contracting muscles you’ll sooner or later experience muscle fatigue. Therefore, weaker muscles are the result of constantly tight muscles.)

So, if you get adjusted beforehand, then the muscles will be stronger, work more efficiently, and actually strengthen more properly.

Of course, then you’ll have muscles that are fatigued from exercise, cause reflexive joint inhibition, and the aforementioned process starts all over again. So you’ll need an adjustment again. That being said, you’ll get yourself to a point where you’ll actually be able to exercise without the need of an adjustment so frequently. Which is where most of us Chiropractors are at and some of our patients.

Many of the elite athletes have gotten to that understanding. They have really come to know their bodies well. They are so in tune with the feedback mechanisms that it’s amazing.

Thank you for reading,

Dr. Steven Lehmann

Cost of back pain (part 2)

Part 2- Back Pain and Costs: As previously mentioned, the costs of back surgeries can run as high as $169,000 for a lumbar fusion and $112,000 for a cervical fusion. In 2010, researchers reviewed the Ohio BWC’s data of 1,450 patients diagnosed with either lumbar disc degeneration, herniation, or radiculopathy. Half of the aforementioned group went through lumbar disc fusion surgery for 2 or more vertebrae. The other half didn’t have surgery even though they had similar diagnoses.

After 2 years post surgical, only 26% of those patients who had surgery had returned to work. The non-surgical group comparatively had a 67% return to work rate. The surgical group (again nearly half of 1,450 patients) had a 36% complication rate with a re operation rate of 27%.

The most eye opening fact was that researchers determined there was a 41% increased use in pain killer usage. And that 76% of patients continued opioid medication use after surgery. A shocking 17 of the post surgical patients actually died during the course of this study!
A review of pain management therapies by R. Norman Harden, MD in the American Pain Management Bulletin states “we practice at a time when unproven experimental, invasive, and expensive procedures are often compensated without question. Many of the surgical and interventional techniques have never been subjected to evidence based inquiry. Oddly, the FDA approves devices and procedures relatively easily … in this context, there has been a proliferation of extremely goofy therapies, which are expensive at best, and downright dangerous at worst.”
Another criticism of epidural steroid injections appeared in the American Pain Society Bulletin by Steven H. Sanders, PhD, who revealed nerve blocks for back pain are not supported by scientific research: “From the current review, we must conclude injections and nerve blocks produce a large amount of money with very little science to support their application.”

Part 3- Back Pain and Costs: Medical Myths

“But my doctor told me I need a back surgery!” I’m sure he did, but did you know that of the nearly 500,000 plus back surgeries performed annually only about 10% were necessary? Dr. Richard Deyo, MD, MPH is quoted as saying, , “It seems implausible that the number of patients with the most complex spinal pathology increased 15-fold in just six years,” and he mentioned one strong motivation included “financial incentives involving both surgeons and hospitals.”

In 1994, Drs. Cherkin and Deyo performed a study that examined the international rates of spinal surgery with that of the United States. They found that back surgery rates in the USA were nearly 40% higher than that of any other country. They also determined that back surgery rates in the U.S. were 5 times higher than that of England or Scotland (socialized medicine is practiced there). It was apparent to Deyo and Cherkin that the excessive number of neurosurgeons and orthopedic surgeons had a linear on the number of surgeries performed per capita. Basically said, since we have so many surgeons over here, then we can expect each one of them to do more than their share.

But you’re going to tell me that an MRI or a CT scan revealed this large herniation. I’m sure it did, but did you know that a repeatable study employing an MRI on 100 and a 1,000 pain free patients, who never had back pain, revealed 30% of these people had bulging or herniated discs, but were pain free! It’s not surprising that in areas of the world (and of course the US) where MRIs and CT scans are in high numbers that they also have a high correlation of back surgeries.

I personally have seen patients with lumbar strains, facet syndromes, arthritis anteriorly and posteriorly, and mild stenosis who also had positive MRIs for disc herniations of bulges, but their source of pain wasn’t from a disc herniation. And when I treated their cause they responded. The med docs aren’t alone. I too have seen MRIs with large disc lesions that I referred out to surgeons only to hear the patient be told to return to my care for a few more weeks of conservative treatment and ultimately they didn’t need surgery. Or the patients who refused surgery after being referred out who later became symptom free.

The problem isn’t just the abundance of surgeons or imaging facilities, the problem is that doctors are often not treating the biomechanical causes of patients’ back pain. Even covering up the pain with narcotics, steroids, and injections isn’t treating the true cause of their pain. All too often doctors rely on radiographic findings rather than a good history and examination. Many of my patients tell me that their exam was lacking, the doctor never touched them, or worse yet they were examined by a non-physician (nurse or physical therapist). My question is how do you determine which structures are actually at fault or injured if you don’t examine the patient fully.

Continued-

“But my medical doctor doesn’t believe in Chiropractic and wants to send me to a surgeon.”

First off, we’re a profession, not a therapy. Chiropractic is a profession. What we do is adjust or manipulate and more. Many of my colleagues perform acupuncture, taping, rehab., nutritional and diet counseling, sports medicine, neurology, imaging interpretation, mid-wifery, pediatrics, applied kinesiology, reflexology, and much more. You don’t just clap your hands and believe in us. How unscientific is that comment?

The Costs of Back Pain (part 1)

Back pain and costs: On the top ten list of diseases in America, low back pain is listed as #8. According to Forbes it costs us $40 billion annually. Low back pain sent over 3 million people to the hospital emergency rooms in 2008 at a cost of $9.5 billion. Low back pain ranked as the 9th most expensive condition treated in U.S. hospitals that year.

In spite of the overwhelming research and the new wave of data that proves much of the current medical/allopathic treatments are ineffective and costly; the medical establishment across the US has failed to read or heed the data and research. They continue to prescribe opiates, epidural steroid injections, and radical surgeries despite the warnings of their peers.

The costs of back surgery are staggering and are among the most expensive. Not including costs such as hospitalizations, imaging, drugs & medications, iatrogenic injuries, and other associated costs; the base costs are listed below:
 Anterior cervical fusion: $44,000
 Cervical fusion: $19,850
 Decompression back surgery: $24,000
 Lumbar laminectomy: $18,000
 Lumbar spinal fusion: $34,500

Dr. Richard Deyo, MD, MPH found that when combined with surgical costs, MRIs, rehab, and disability, spine surgery costs approach $100,000. And the direct costs for lumbar spinal fusion may reach as high as $169,000. A cervical Fusion can cost as high as $112,000.

In 1998 a research study was published in the Annals of Internal Medicine by Dr. Paul G. Shekelle, an internist with the West L.A. Veterans Affairs Medical Center and the UCLA’s RAND corp. He found that chiropractic manipulation was effective for over 46% of the people it was administered to. The research also found that 29% of the study group had chiropractic inappropriately used as a treatment, which means only 25% of appropriately selected patients failed to respond to chiropractic care.

In 24 years of practice as a chiropractic physician I would say that an 85 % success/failure rate is about what my patients and I have experienced. So the aforementioned study isn’t as accurate as real life practice would suggest. I have also learned which cases are going to respond to chiropractic and which ones don’t. So a 29% rate for inappropriate usage of chiropractic as a treatment is also higher than I experience in real life practice. No disrespect to Dr. Skekelle intended.

Lastly, Dr. Shekelle opined of his study, “instead of thinking of chiropractic as an alternative or some kind of therapy separate from other care, we really should consider it equivalent.” He went on to say, “our study basically provides the first systematic look at the quality of chiropractic care.” I believe he was pleasantly impressed with what he saw.