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Back and Leg Pain (Lumbar Radiculopathy)  as a Result of Disc Herniation and the Long Term Effect of Chiropractic Care


90% of all low back-lumbar disc herniation patients got better with chiropractic care



By

Mark Studin DC, FASBE (C), DAAPM, DAAMLP
 

The term "herniated disc" has been called many things from a slipped disc to a bulging disc. For a doctor who specializes in disc problems, the term is critical because it tells him/her how to create a prognosis and subsequent treatment plan for a patient. To clarify the disc issue, a herniated disc is where a disc tears and the internal material of the disc, called the nucleus pulposis, extends through that tear. It is always results from trauma or an accident. A bulging disc is a degenerative "wear and tear" phenomenon where the internal material or nucleus pulposis does not extend through the disc because there has been no tear, but the walls of the disc have been thinned from degeneration and the internal disc material creates pressure with thinned external walls. The disc itself "spreads out" or bulges.

There are various forms and degrees of disc issues, but the biggest concern of the specialist is whether nerves are being affected that can cause significant pain or other problems. The problem exists when the disc, as a result of a herniation or bulge, is touching or compressing those neurological elements, which is comprised of either the spinal cord, the nerve root (a nerve the extends from the spinal cord) or the covering of the nerves, called the thecal sac.

With regard to the structure that we have just discussed, the doctor must wonder what the herniation of the neurological element has caused. In this scenario, there are 2 possible problems, the spinal cord and nerve root. If the disc has compromised the spinal cord, it is called a myelopathy (my-e-lo-pathy). You have a compression of the spinal cord and problems with your arms or legs. An immediate visit to the neurosurgeon is warranted for a surgical consultation. The second problem is when the disc is effecting the spinal nerve root, called a radiculopathy. It is a very common problem. A doctor of chiropractic experienced in treating radiculopathy has to determine if there is enough room between the disc and the nerve in order to determine if a surgical consultation is warranted or if he/she can safely treat you. This is done by a thorough clinical examination and in many cases, an MRI is required to make a final diagnosis. Most patients do not need a surgical consultation and can be safely treated by an experienced chiropractor.

While herniations can occur anywhere, it was reported by
Jordan, Konstanttinou, & O'Dowd (2009)  that 95% occur in the lower back.  "The highest prevalence is among people aged 30–50 years, with a male to female ratio of 2:1. In people aged 25–55 years, about 95% of herniated discs occur at the lower lumbar spine (L4/5 and L5/S1 level); disc herniation above this level is more common in people aged over 55 years" (http://clinicalevidence.bmj.com/ceweb/conditions/msd/1118/1118_background.jsp#incidence).

It was reported by Aspegren et al. (2009) that 80% of the chiropractic patients studied with both neck and low back (cervical and lumbar) disc herniations had a good clinical outcome with post-care visual analog scores under 2 [0 to 10 with 0 being no pain and 10 being the worst pain imaginable] and resolution of abnormal clinical examination findings. Anatomically, after repeat MRI scans, 63% of the patients studied revealed a reduced size or completely resorbed disc herniation. A study by Murphy, Hurwitz, and McGovern (2009) focused only on low back (lumbar) disc herniations and concluded that, "Nearly 90% of patients reported their outcome to be either 'excellent' or 'good'...clinically meaningful improvement in pain intensity was seen in 74% of patients (p. 729)." The researchers also concluded that the improvements from chiropractic care was maintained for 14 1/2 months, the length of the study, indicating this isn't a temporary, but a long-term solution. It was reported by BenEliyahu (1996) that 78% percent of the low back-lumbar disc herniation patients were able to return to work in their pre-disability occupations, which is the result of the 90% of all low back-lumbar disc herniation patients getting better with chiropractic care as discussed above.

These are the reasons that chiropractic has been, and needs to be, considered for the primary care for low back-lumbar disc herniations with resultant pain in the back or legs.
This study along with many others concludes that a drug-free approach of chiropractic care is one of the best solutions for herniated discs and low back or leg pain.


References:
1. Jordan, J., Konstanttinou, K., & O'Dowd, J. (2009, March 26). Herniated lumbar disc. Clinical Evidence. Retrieved from http://clinicalevidence.bmj.com/ceweb/conditions/msd/1118/1118_background.jsp#incidence
2. Aspegren, D., Enebo, B. A., Miller, M., White, L., Akuthota, V., Hyde, T. E., & Cox, J. M. (2009). Functional scores and subjective responses of injured workers with back or neck pain treated with chiropractic care in an integrative program: A retrospective analysis of 100 cases. Journal Manipulative Physiological Therapy 32(9), 765-771.
3. Murphy, D. R., Hurwitz, E. L., & McGovern, E. E. (2009). A nonsurgical approach to the management of patients with lumbar radiculopathy secondary to herniated disk: A prospective observational cohort study with follow-up. Journal Manipulative Physiological Therapy, (32)9, 723-733.

4. BenEliyahu, D. J. (1996). Magnetic resonance imaging and clinical follow-up: Study of 27 patients receiving chiropractic care for cervical and lumbar disc herniations. Journal Manipulative Physiological Therapy, 19(9), 597-606.

New Study Says if you have a hermiated disc and arm pain you can expect to get 86 percent improved at three months of chiropractic treatment!

How do patients with cervical disk protrusion and radiculopathy respond to osseous Spinal Manipulative Therapy?

METHODS: Fifty patients were recruited from a Swiss chiropractic practice. Aged between 18 and 65, they had neck pain and moderate-to-severe arm pain in a dermatomal pattern; sensory, motor or reflex changes corresponding to the involved nerve root; and no contraindications to cervical SMT. At least one positive orthopedic test for radiculopathy was required. Exclusion criteria included spinal myelopathy, spinal stenosis and previous spinal surgery. Outcome measures included the Numeric Rating Scale (0-10), the Neck Disability Index (NDI) and the patients’ global impressions of change (PGIC). Patients were assessed at two weeks, one month and three months. Treatment occurred three to fives times per week for two to four weeks, and then one to three times per week until the patient was asymptomatic. Patients were allowed OTC pain medications.

OF NOTE: SMT was performed “at the spinal level clinically assessed to correspond with the MRI findings.” HVLA was applied “with the goal of moving the affected segment and producing an audible release.” If audible release was not achieved during the first thrust, the DC could try twice more.

RESULTS: Fifty patients provided data at baseline and three months. The average patient was 44 years old. About a third were male. After the initial two weeks of treatment, 55.3 percent were significantly improved. None reported being worse. The percentage of improved patients continually rose during treatment. One patient was slightly worse at one month but reported improvement after three months. Statistically and clinically significant reductions in NRS and NDI scores occurred throughout the study. Specifically, patients’ PGIC were as follows: At week two, 55.3 percent were much better or better; at one month, 68.9 percent were much better or better (2.2 percent slightly worse); at three months, 85.7 percent were much better or better. Regarding functional outcomes of the numerical rating scale for neck pain (NRS) (0-10), the average baseline was 5.71 (SD, 2.98); week two, 3.54 (SD, 2.17), one month, 2.58 (SD, 1.97) and three months, 1.68 (SD, 1.72). Regarding NRS for arm pain, the average baseline was 6.43 (SD, 2.77); week two, 4.12 (SD, 2.58), one month, 2.71 (SD, 2.19) and three months, 1.64 (SD, 1.84). Baseline neck disability index (NDI) was 18.17 (SD, 8.71); week two, 14.12 (SD, 8.52), one month, 9.15 (SD, 5.15) and three months, 4.95 (SD, 4.29). These outcome data were reported statistically significant p<0.0001.

The authors also divided the patients into groups of acute and chronic (> 4 weeks duration). Not surprisingly, acute patients saw a faster and further decline in NDI, NRS and PGIC scores (86 percent improved at three months vs. 76 percent for chronic CDH patients). It should be noted that the chronic group’s improvement was still statistically/ clinically significant.

STUDY CONCLUSION: Spinal Manipulative Therapy  for acute, subacute and chronic patients with CDH in this study produced significant improvement in symptoms with no adverse effects.

Peterson C, Schmid C, Leeman S, Anklin B, and Humphreys BK. Outcomes from magnetic resonance imaging — confirmed symptomatic cervical disk protrusion patients treated with high-velocity, low-amplitude spinal manipulative therapy: a prospective cohort study with 3-month follow-up. J Manipulative Physiol Ther 2013;36(8):461-7.