Prevention of Back Pain and Treatments

1. Prevention of Back Pain and Treatments By: Dawn Basciani, DC Brighton Hill Chiropractic

2. Prevalence of Back Pain: • According to the Spine Journal, 80% of Americans experience low back pain (LBP) in their lifetime • 2-8% have chronic back pain (CBP) lasting more than 3 months • 3-4% of the population is temporarily disabled due to back pain • 1 % of the working-age population is disabled completely and permanently as a result of LBP (Martin et al., 2009)

3. Main cause of disability among civilian noninstitutionalizedU.S.adults aged ≥18 years with self-reported disabilities, estimated affected population, and percentages, in the US, 2005 U.S. Census Bureau, Survey of Income and Program Participation, 2004 Panel, Wave 5, June--September 2005.

4. Chronic back pain (CBP) is common, costly, and disabling according to Spine Journal: • LBP is the 2nd leading cause of lost work time • LBP is the 3rd most common reason to undergo a surgical procedure • LBP is the 5th most frequent cause of hospitalization (Martin, B.I., Turner, J.A., Mirza, S.K., et al., 2009)

5. Tips for Back Pain Prevention: • Maintain a healthy diet and weight • Remain active • Avoid prolonged inactivity or bed rest • Warm up or stretch before exercising • Maintain proper posture • Wear comfortable, low-heeled shoes • Sleep on a mattress of medium firmness to minimize any curve in your spine • Use proper lifting technique • Ergonomically correct workstation (American Chiropractic Association, 2013)

6. Workplace Ergonomics: The Desk • Choose a desk that is the proper height • Feet should be touching the floor, with the legs and body forming an angle of 90-110 degrees • Body should be straight with the head and neck upright and looking forward, avoiding slouching • The eyes are should be at the same height as the top of the monitor • Wrists should be straight when typing, shoulders perpendicular to floor, and forearms parallel to the floor • Headset should be used when talking on the phone • Stand up and stretch with a short walk and/or simple stretches every 20-30 min (American Chiropractic Association, 2013)

7. (http://wikieducator.org/Ergonomics_posture)

8. Proper Lifting Techniques: • keep the weight as close to the body as possible • bend at the knees, using the stronger leg muscles to do the lifting • provide balance to the back by tightening the abdominal muscles and tucking in the pelvis • when bending and lifting, the trunk should not twist, but should be erect with the knees bent so that muscle coordination takes place (Potter & Perry, 2009)

9. (http://what-when-how.com/nursing/body-mechanics-and-positioning-client-care-nursing-part-1/)(http://what-when-how.com/nursing/body-mechanics-and-positioning-client-care-nursing-part-1/)

10. Posture Problems: (http://www.swolept.com/posts/posture-tricks-to-make-your-butt-and-gut-smaller-addressing-anterior-pelvic-tilt#.UbhYlJwfJdY)

11. Pelvic Tilt Exercises: • Lie on your back with your knees bent • "Brace" your stomach-tighten your muscles by pulling in and imagining your belly button moving toward your spine. Your back should be pressing to the floor and your hips and pelvis are rocking back • Hold for about 6 seconds • Repeat 8-12 times (Healthwise, 2010)

12. Low Back Stretching: (Why I Exercise, 2012)

13. Low Back Stretching: (Why I Exercise, 2012)

14. Low Back Stretching: (Why I Exercise, 2012)

15. Low Back Stretching: (Why I Exercise, 2012)

16. Low Back Stretching: (Why I Exercise, 2012)

17. Low Back Strengthening: (Why I Exercise, 2012)

18. Low Back Strengthening: (Why I Exercise, 2012)

19. Low Back Strengthening: (Why I Exercise, 2012)

20. Low Back Strengthening: (Why I Exercise, 2012)

21. Low Back Strengthening: (Why I Exercise, 2012)

22. The Truth about Fish OilOMEGA-3 FATTY ACIDS •  A study published in the New England Journal of Medicine noted that prescription NSAIDs for rheumatoid and degenerative arthritis alone conservatively accounted for a minimum of 16,500 fatal bleeding deaths per year in the US, which is the 15th leading cause of death in the US • Most cox-enzyme inhibiting pain drugs known as non-steroidal anti-inflammatory drugs (NSAIDs) inhibit both cox-1 and cox-2 enzymes. • blocking the cox-1 enzyme resulted in significant bleeding problems • blocking of the cox-2 enzyme is what was responsible for pain reduction (New England Journal of Medicine, 1999)

23. Non-drug alternative to the treatment of chronic spine pain was recommended at the 73rd meeting of the American Association of Neurological Surgeons: • Omega-3 fatty acids were recommended as they block the cox-2 enzyme responsible for pain • Omega-3 fatty acids (fish oil) is an safe and effective anti-inflammatory alternative to NSAIDs for discogenic pain • NSAIDs are associated with “extreme complications, including gastric ulcers, bleeding, myocardial infarction, and even deaths.”  • “An alternative treatment with fewer side effects that also reduces the inflammatory response and thereby reduces pain is believed to be omega-3 EFAs found in fish oil”  • At an average of 75 days on fish oil, 59% discontinued taking their prescription NSAIDs for pain   • “fish oil supplements appear to be a safer alternative to NSAIDs for treatment of nonsurgical neck or back pain.” (Surgical Neurology, 2006)

24. Omega-3 fatty acids (fish oil) Dose Recommendations: Children: • The DHA should be greater than the EPA (2.6/1) • 900 mg of EPA + DHA per day Adults: • Has an ideal ratio of ALA, EPA, DHA, and GLA; EPA should be double DHA • 3,000 mg of EPA + DHA per day (Nutri-West, n.d.)

25. Non-pharmacologic Therapies to benefit and improve pain or function in CBP: • spinal manipulation • acupuncture • exercise therapy • stretching, and strengthening • massage therapy • yoga • behavioral therapy (American Chronic Pain Association, 2008, p.10)

26. What is Chiropractic? • “Health care profession that focuses on disorders of the musculoskeletal system and the nervous system, and the effects of these disorders on general health” • Hands-on approach including patient examination, diagnosis, and treatment • Most common therapeutic procedure performed by Chiropractors - spinal manipulation • Purpose of manipulation – to restore joint mobility by manually applying a controlled force into joints that have become restricted in their movement as a result of a tissue injury • Injured tissues undergo physical and chemical changes that can cause inflammation, pain, and diminished function • Spinal manipulation helps to alleviate pain and muscle tightness, allowing tissues to heal (American Chiropractic Association, 2013)

27. A retrospective analysis of 70,274 member-months in a 7-year period within an IPA, comparing medical management to chiropractic management, demonstrated decreases of: • 60.2% in-hospital admissions, • 59.0% hospital days, • 62.0% outpatient surgeries and procedures, • and 83% pharmaceutical costs when compared with conventional medicine IPA performance. This clearly demonstrates that chiropractic nonsurgical nonpharmaceutical approaches generates reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone. (Journal of Manipulative and Physiological Therapeutics, 2007)

28. Consumer Reports April 2009 The Consumer Reports Health Ratings Center recently surveyed more than 14,000 subscribers who experienced lower-back pain in the past year but never had back surgery. Hands-on treatments were rated by lower- back-pain sufferers as very helpful. Professional Highly Satisfied Chiropractor 59% Physical Therapist 55% Acupuncturist 53% Physician, specialist 44% Physician, PCP 34%Source: Consumer Reports Health Ratings Center http://www.consumerreports.org/health/conditions-and-treatments/back-pain/overview/back-pain.htm

29. Comparison of Competency test in Musculoskeletal Medicine: Journal of Bone and Joint Surgery 1998Journal of the American Osteopathic Association 2006Journal of Manipulative & Physiological Therapeutics 2007

30. Medications for CBP: • Acetaminophen (Tylenol) - over-the-counter • Non-selective Non-steroidal anti-inflammatory drugs (NSAIDS) - more effective than acetaminophen, but have an increased risk of stomach ulcers. The FDA also recently required warnings for all NSAIDS about potential risk of heart attacks • COX-2s are a type of NSAIDS that are safer on the stomach, but there is a risk of heart attack • Opioids - powerful pain pills • Muscle relaxants - short term relief, frequently associated with sedation and fatigue • Antidepressants - benefits are likely small, not recommended as a first-line option • Herbal therapies - willow bark, devil’s claw, and cayenne • Gabapentin - anticonvulsant, short-term relief for patients with nerve pain (radiculopathy), only been evaluated in a few small studies • Corticosteroid pills and injections - not recommended for treatment of LBP because they have not been shown to be effective (American Chronic Pain Association, 2008, p.10)

31. Injections for CBP: • For LBP related to sciatica due to a herniated disc, an injection of corticosteroids into the epidural space (the space around the spinal cord) may help decrease swelling and relieve symptoms of back pain • Benefits are generally short-term • “none of these therapies have been proven to be beneficial in well-conducted clinical trials and are not recommended in most cases” (American Chronic Pain Association, 2008, p. 11)

32. Surgery for CBP: • “Surgery for non-specific low back pain should be considered only after several noninvasive therapies have not worked” • Back pain associated with a herniated disc or spinal stenosis (presence of back pain and leg pain) surgery may be considered when the symptoms are not getting better after 4-6 weeks • Most of the benefits seen with surgery occur in the 1st year, after which people treated with surgery and without surgery do about the same • Recommendation based on evidence – “surgery is not required even when a herniated disc or spinal stenosis cause persistent symptoms” (American Chronic Pain Association, 2008, p. 11)

33. Chiropractic part of the team: • Patient centric • Team based care • Optimizes skills & competencies of the care team • Results oriented in improving the health and health care of the individual An integral team member

34. Thank you to the CNY Chapter of the American Society of Safety Engineers for inviting me to your holiday party to talk about back prevention Questions?

35. References: • American Chronic Pain Association. (2013). Retrieved from http://www.theacpa.org/ • American Chronic Pain Association. (2008). Consumers’ Guide Practice Guidelines For Low Back Pain Retrieved from http://www.theacpa.org/uploads/documents/Consumer%20Guidelines%20for%20Low%20Back%20PainFinal%202-6-08.pdf • American Chiropractic Association. (2013). Workplace Erogonomics. Retrieved from http://www.acatoday.org/content_css.cfm?CID=3130 • American Chiropractic Association. (2013). Chronic Pain and Depression. Retrieved from http://www.acatoday.org/content_css.cfm?CID=2187 • American Chiropractic Association. (2013). Back Pain and Chiropractic. Retrieved from http://www.acatoday.org/content_css.cfm?CID=1420 • Clinical Utilization and Cost Outcomes from an Integrative Medicine Independent Physician Association: An Additional 3-year Update. Journal of Manipulative and Physiological Therapeutics. 2007 (May); Vol:30 (4): pp.263–269. • Keller, R.B. (2010). Pelvic Tilt Exercise. WebMD. Retrieved from http://www.webmd.com/fitness-exercise/pelvic-tilt-exercise • Maroon, J.C., Bost, J.W. (2006). Omega-3 fatty acids (fish oil) as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surgical Neurology, 65(4). 326-31.

36. References: • Martin, B.I., Turner, J.A., Mirza, S.K., et al. (2009). Trends in health care expenditures, utilization, and health status among US adults with spine problems, 1997–2006. Spine, 1;34(19):2077-84. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/19675510 • Potter, P., Perry, A., Stockert, P., & Hall, A. (2009). Fundamentals of nursing. (8th ed.). St. Louis : Elsevier Mosby. • U.S. Department of Health and HumanServices. (n.d.).Arthritis, Osteoporosis, and Chronic Back Conditions. Healthy People 2020. Retrieved April 26, 2013 from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=3 • U.S. Census Bureau, Survey of Income and Program Participation, 2004 Panel, Wave 5, June--September 2005. • Why I Exercise. (2012). [Photograph of Low Back Exercises]. Retrieved from http://www.whyiexercise.com/ • Why I Exercise. (2012). [Photograph of Low Back Exercises]. Retrieved from http://www.whyiexercise.com/ • University of Southern California Neurosurgery. (2010). [Photograph of Low Back Spine Conditions]. Retrieved from http://www.uscneurosurgery.com/conditions/spine-center/expertise/degenerative-spine-disease.php • Wolfe M.M., Lichtenstein D.R., Singh G. (1999). Gastrointestinal Toxicity of NonsteroidalAntiinflammatory Drugs. New England Journal of Medicine, 340(24). 1888-1899.