CAM for back pain 2

Placebo effect
– A change in a patient’s illness due to the symbolic part of treatment rather than a scientific or pharmacological property. Based on belief that it will work.
– A self-made healing response of the body that is natural, may not even require a placebo. Mind’s effect on body
– Not completely understood

Manual therapies
– Include spinal manipulation, joint mobilization, massage
– Massage – increases local blood flow, improves lymph drainage and pain suppression mechanisms, causing tissue repair, pain reduction and improved mood.
– Osteopathic manual therapy – works on soft tissue as well as spinal manipulation. Attempts to help the body heal itself through the neuromuscular system.

Spinal manipulative therapy
– Adjusting the spine through twisting/pulling/pushing/massage/pressure to loosen/move the causes of pain (spinal bones/joint structures)
– Improves spinal mobility, supporting joint cartilage and IV discs
– Should involve exercises that strengthen the muscles to better support the joints.
– May be performed by a chiropractor, or physio
– Should not be counted on alone to treat low back pain
– Benefit is usually noticed after a single therapy, and long-term manipulation is not proven to help. Works for some but not others
– Effective short term but not long term
– Spinal manipulation shown to be equivalent to physiotherapy or exercise
– Risks due to lack of standards in field (careful with neck manipulation esp.)

http://serendip.brynmawr.edu/bb/neuro/neuro99/web1/Kinser.html
http://www.healingchronicpain.org/content/introduction/comp_manual.asp
http://www.bchealthguide.org/kbase/dp/topic/tu6488/dp.htm

DEFINITION AND INCIDENCE OF SCIATICA

Sciatica is defined as a set of symptoms including pain felt along the path of the sciatic nerve. It may be caused by compression/irritation of one of the five nerve roots that give rise to the sciatic nerve, or that of the nerve itself. Pain can be felt in the lower back, buttocks, or the leg and foot. Pain is sometimes severe. Other symptoms include, anesthesia, parasthesia, muscle weakness, and difficulty of motion. It is important to note that sciatica is a set of symptoms, not a diagnosis for what is irritating the nerve.

The incidence of sciatica varies from study to study, with figures ranging from between 1-10%. However, it has been shown that males are more likely to have these symptoms. In a study done in the 1980’s in Finland, 5.1% of males and 3.7% of females aged over 30 had lumbar disk disease, a common cause of sciatica.

Claudication is defined as pain and/or cramping in the lower leg due to inadequate blood supply to the muscles. The pain usually causes the patient to limp (claudication derives from the latin ‘claudicare’, meaning ‘to limp’). The pain is normally felt with exertion, but in severe cases, is felt at rest as well.

Complications and Prognosis of Sciatica

Complications and prognosis for Sciatica
Prognosis
If the cause of the sciatic nerve dysfunction can be identified and successfully treated, full recovery is possible. The extent of disability varies from no disability to partial or complete loss of movement or sensation. Nerve pain may be severe and persist for a prolonged period of time.

Complications
• Partial or complete loss of leg movement
• Partial or complete loss of sensation in the leg
• Recurrent or unnoticed injury to the leg
• Side effects of medications

Because this was so brief i thought i would add in the Complications and Prognosis for a Prolapsed Disc

Prognosis

Most people will improve with conservative treatment. A small percentage may continue to have chronic back pain even after treatment.

It may take several months to a year or more to resume all activities without pain or strain to the back. People with certain occupations that involve heavy lifting or back strain may need to change job activities to avoid recurrent back injury.

Possible Complications

• Long-term back pain
• Loss of movement or sensation in the legs or feet
• Loss of bowel and bladder function
• Permanent spinal cord injury (very rare)

http://www.nlm.nih.gov/MEDLINEPLUS/ency/article/000442.htm
Sarah

PCL 10- Sciatica Symptoms

Pain is the most common symptom. Usually, a pain (ranges from mild ache to severe) starts low on one side of the back and then shoots down the buttock (deep) and the calf. Sensations like ‘tingling’, ‘electric shocks’, ‘pins and needles’, numbness and muscle weakness in leg can be felt by the patient.

· The pain is usually worse with both prolonged sitting and standing.

· In most people, the pain is made worse by bending backwards, sneezing, coughing, laughing, or a hard bowel movement.

· Weakness in your leg or foot, along with the pain. The weakness may become so bad you can't move your foot.

· Rare: loss of bladder or bowel control indicate cauda equine syndrome, medical emergency

Causes

· Herniated disk

· Osteophytes (bony growths)

o At spine, rubbing of bone spurs against Sciatic nerve

· Piriformis syndrome

o Uncommon

o Sciatic nerve runs directly underneath

o When piriformis goes into spasm or is swollen, SN is compressed

· Spondylolisthesis

o Sublaxation, roots of SN compressed

· Pregnancy

o Can cause pressure on SN

Reference

http://www.emedicinehealth.com/sciatica/page3_em.htm

http://www.mydr.com.au/default.asp?Article=4196

Thoracolumbar spine examination

ASK
Ask for consent
Ask if they have any pain at present
Ask them to tell you if they feel pain at any time during the examination
Ask them to undress

LOOK
Look at their posture
Look for deformities, from both back and side view
Look for normal thoracic kyphosis and lumbar lordosis
Look for scoliosis (C shaped or S shaped curvature laterally)

FEEL
Feel each vertebral body for tenderness and muscle spasm (start at the top and work downwards)

MOVEMENT
Flexion: ask the patient to touch their toes with their knees straight
Extension: ask the patient to lean backwards
This is usually less painful than bending forwards for patients with back pain
Lateral bending: ask the patient to slide the right hand down the right leg, then same for left
Rotation: have the patient sitting and ask them to rotate to each side (NB this is thoracic not lumbar spine)

MEASURE
Schober's test: Find the posterior iliac spine (around L5) and mark points 5cm below and 10cm above it. Then ask patient to touch their toes. The distance should increase at to at least 20cm, any less indications limitation on lumbar flexion
Straight Leg Raising test: With the patient lying down, lift the straightened leg. Normal is 80-90 degrees, a disc prolapse will limit this to less than 60 degrees.

Risk Factors and Causes of Sciatica - Michelle

Six most common causes of sciatica:
1. bulging or herniated disc
2. lumbar spinal stenosis
3. spondylolisthesis
4. trauma
5. piriformis syndrome
6. spinal tumours or infections
other causes: sacroiliitis, lumbar facet joint syndrome, iliolumbar syndrome, pregnancy

Risk factors:
-Occupation which involves lifting heavy objects, twisting the back or driving a motor vehicle for long periods.
-Prolonged sitting/sedentary lifestyle
-Age
: Intervertebral discs begin to deteriorate, lose moisture, and shrink by age 30
: One third of adults over 20 show evidence of herniated discs, although only 3% show symptoms
-Genetic factors eg. Inherited Spinal Structure Abnormalities or Inherited Weakened Discs (studies are finding that mutations in the COL9A gene, a gene involved in producing collagen making the discs less able to resist compression, may play a role in 10% of sciatica cases)
-Diabetes increases risk of nerve damage
-Constant walking and running can cause piriformis syndrome

PCL 10 Siatica Medical Management - Myat

• Self Management

For most people, sciatica responds well to self-care measures. These may include:
- use of hot packs
- cold packs
- stretching
- exercise
- use of OTC medications

• Physical Therapy

If you have a herniated disk, physical therapy can play a vital role in your recovery. Once acute pain improves, your doctor or a physical therapist can design a rehabilitation program to help prevent recurrent injuries.

Rehabilitation typically includes exercises to help correct your posture, strengthen the muscles supporting your back and improve your flexibility. Your doctor will have you start physical therapy, exercise or both as early as possible. It's the cornerstone of your treatment program and should become part of your permanent routine at home.

• Prescription Drugs

- anti-inflammatory with muscle relaxation
- narcotics for short term pain relief
- tricyclic antidepressants (increase endorphins)
- anticonvlusants (block pain pathways)

• Epidural Steroid Injections (more aggressive)

In some cases, your doctor may inject a corticosteroid medication into the affected area. Corticosteroids mimic the effects of the hormones cortisone and hydrocortisone, which are made by the outer layer (cortex) of your adrenal glands. When prescribed in doses that exceed your natural levels, corticosteroids suppress inflammation around the irritated nerve, thereby helping to relieve pain.

Their usefulness in treating sciatica remains a matter of debate. Some research has found that corticosteroids can provide short-term symptom relief, but that these medications aren't a long-term solution. In addition, corticosteroids can have side effects, so the number of injections you can receive is limited — usually no more than three in one year.

http://www.mayoclinic.com/health/sciatica/DS00516/DSECTION=treatments-and-drugs

CAM for Sciatica - Eunice

CAM for Sciatica

Acupuncture: Involves the insertion of fine needles into the skin at traditional acupuncture points which are believed to sit on meridians which run through the body.

- Thought to decrease pain by increasing the release of endorphins, which block pain. Many acu-points are near nerves. When stimulated, these nerves cause a dull ache or feeling of fullness in the muscle. The stimulated muscle sends a message to the central nervous system (the brain and spinal cord), causing the release of endorphins (morphine-like chemicals produced in our own bodies during times of pain or stress). Endorphins, along with other neurotransmitters (body chemicals that modify nerve impulses), block the message of pain from being delivered up to the brain
- At present, there is not enough evidence to recommend acupuncture in the treatment of sciatica, but some people do gain relief
- Dummy acupuncture: uses non-traditional acupuncture points, which some people say is still beneficial

Mind-body therapies: aim to address psychological factors which affect intensity of pain and disability associated with chronic pain.

- Use various approaches: relaxation techniques, meditation, guided imagery, biofeedback, and hypnosis
- Benefits: greater sense of control, improved coping skills, decreased pain intensity and distress, changes in the way pain is perceived and understood and increased sense of well being and relaxation.
- Can improve recovery time and reduce pain following surgical procedures
- Evidence in support of these approaches is very strong

Alexander Technique: focuses on self-perception of movement, is a method of rediscovering natural balance and poise through thinking in activity

- Usually involves hands-on coaching by a qualified teacher
- Teacher provides verbal instructions while monitoring and guiding with hands-on assistance in order to help the student to change their previous physical habits.
- Helps to develop an even distribution of muscle tone, using philosophy of ‘good use’: using and moving the body lightly, with a minimum of interference in the interrelationship of neck, head and back. Emphasis on good posture and poise.
- “Every thought we have registers somewhere in our muscles, so the way we think about ourselves is a vital element.”
- Benefits: alleviates pain and weakness as a result of poor posture or repetitive demands, improves pain management for chronic disabilities, and enhanced rehabilitation following surgery or injury.
- A 2008 RCT published in the British Medical Journal found marked improvement in addressing back pain with the technique

http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.Nsf/pages/Alexander_technique?OpenDocument
http://www.healingchronicpain.org/content/introduction/conv_mndbdy.asp
http://www.webmd.com/pain-management/guide/pain-management-alternative-therapy
http://www.mydr.com.au/default.asp?article=4197