Why X-rays Are So Damaging.

X-rays are often used as a marketing tool to capitalise on peoples fear about their alignment & back pain.

Unfortunately there are still some health professionals who routinely x-ray people with back pain, this is despite the national governing bodies that represent chiropractic, medicine, physical therapy all strongly recommend against it. Studies show 90%-95% of back pain has no medical underlying cause, x-rays are notoriously bad at diagnosing the vast majority of back pain, and do more harm than good (see research below)

Some clinics will have on-site x-rays and rather than x-raying approximately 5% as clinically needed they will x-ray almost 100% of back pain sufferers with an obvious financial incentive for the clinic. With the cost of living today, I’m sure most people would rather not waste their hard earned money.

Most things seen on x-rays are just normal wear and tear giving the appearance of bones been misaligned or out. Only a snake oil treatment can claim that bones can magically be put back in (that were never out to begin with). You can take x-rays before treatments that supposedly realign the spine and after and they will be identical to each other. In my experience “fixing alignment” has more to do with justifying charging $80-$90 for a 10 minute treatment or excessive and expensive treatment plans that would otherwise only take 2 or 3 visits.

X-ray findings between people with back pain and without back pain are almost identical, they do not improve outcomes and do more harm than good!

Researchers found no evidence that the use of routine x-rays to assess the function or structure of the spine, improves clinical outcomes and benefits patients.

Researchers in another study concluded; in most cases the potential benefits from routine imaging, including spinal X-rays, do not outweigh the potential harms. The use of spinal X-rays should not be routinely performed in chiropractic practice. (Jenkins 2018)

Another study found routine imaging does not seem to improve clinical outcomes and exposes patients to unnecessary harms & the overuse of imaging also contributes to the high and growing costs associated with low back pain (Chou 2011).

A study published in American Journal of Neuroradiology found many imaging-based degenerative features (arthritis/misalignments) are likely part of normal aging and unassociated with pain. (Brinjiki 2018)

A 2019 study: Imaging in LBP may be associated with higher medical costs, increased healthcare utilization and more absence from work”. (Lemmers 2019)

Another study published in the British Medical Journal found “Imaging may do more harm than good when serious conditions are not suspected and is likely to prolong recovery in patients with non-specific low back pain”. (Hall 2021)

There are dozens of research done over two decades that all have similar findings.

How X-Rays Are Used.

Telling someone who has back pain that their spine is misaligned, arthritic/degenerated or a bone is out of place will only create unnecessary fear & may lead to prolonged recovery and a greater dependence on therapy. Below is what I encounter on a weekly basis from patients who have had unnecessary x-rays taken, I then have to go to great lengths educating and reassuring them their spine is not damaged.

1. Someone with simple back pain, usually muscular gets an x-ray

2. Report of findings: The practitioner tells the back pain sufferer they have lost the curve in their neck, too much curve in their low back, spine is misaligned, hips are out, spine has degenerated etc… Everyone gets told a variation of this.

3. The patient is also told this is what’s causing their pain (it’s not) and several months of treatment is needed some will offer to sell several months of treatment upfront at a reduced cost. With proper treatment most people only need two or three treatments before moving to a more active or self management phase.

4. Revolving door, 5-15 minute treatments with everyone getting the same cookie cutter treatment; two adjustments of the low back/hip, mid back and neck or a slight variation of this.

5. Symptomatic scheduling: 2 treatments a week for 4-6 weeks, one treatment a week for another 4 weeks. When I ask people who get this done why they kept going back when the results were so poor they would often tell me they believed it was normal and they were worried it would get worse if they didn’t.

The irony is the things that actually determine posture or where the body/bones are positioned in space are the muscles and are often seen as incidental.

References

W. Brinjikji,a P.H. Luetmer,a B. Comstock,b,c B.W. Bresnahan,c L.E. Chen,c R.A. Deyo,f S. Halabi,g J.A. Turner,d A.L. Avins,h,i K. James,c J.T. Wald,a D.F. Kallmes,a and J.G. Jarvikc,e Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations AJNR Am J Neuroradiol. 2015 Apr; 36(4): 811–816.

Roger Chou, Amir Qaseem, Douglas K Owens, Paul Shekelle, Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians Ann Intern Med  2011 Feb 1;154(3):181-9.

Amanda M Hall, Kris Aubrey-Bassler, Bradley Thorne, Chris G Maher. Do not routinely offer imaging for uncomplicated low back pain BMJ 2021 Feb 12;372:n291

Hazel J Jenkins , Aron S Downie, Craig S Moore , Simon D French  Current evidence for spinal X-ray use in the chiropractic profession: a narrative review Chiropr Man Therap 2018 Nov.

G P G Lemmers, W van Lankveld, G P Westert, P J Van der Wees, J B Staal. Imaging versus no imaging for low back pain: a systematic review, measuring costs, healthcare utilization and absence from work. Eur Spine J. 2019 May;28(5):937-950.

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Work From Home Survival Guide

With our daily and work lives changing so rapidly and more people working from home, I’m sure many of you have experienced an increase in work related pain and discomfort, fortunately by implementing some healthy spinal habits throughout the day and without needing expensive or specialised ergonomic chairs this can be avoided. The main culprit is not moving or static postures, if you were to sit for an extended period of time with perfect posture you are still likely to feel pain, likewise if you were to stand all day and limit movement, it would also lead to pain and discomfort.

The best antidote to pain is movement.

With the nature of working from home, incidental movement such as walking to and from the home/office, public transport, between meetings and appointments, access to gyms/exercises classes have all been limited, it’s becoming more imperative now than ever people create an artificial demand for movement in our lives. A good way to make use of the time saved on commuting to work can be used to go for a brisk 30-45 minute walk or jog prior to settling into the home office.

Everyone has a different stress capacity or tolerance when it comes to sitting, for some it can be as little as 30-60 minutes for others it could longer, a relaxed muscle with good blood and oxygen supply will have a higher capacity, if a muscle is tense, it gets fatigued much quicker, lactic acid develops and tension & discomfort usually follows. Similar to holding a tight fist, it doesn’t take too long before tension and discomfort is felt in the hand and forearm muscles, compared to a relaxed hand.

Make a note how long you sit for before the muscles feel tense and uncomfortable and try to get roughly 5-10 minutes of exercise just prior to the onset of pain; things such as air squats, hip and shoulder rotations, push ups, body weight lunges can all be used to great effect, do these at regular intervals as needed throughout the day.

Try have a couple of alternate setups, it could be as simple as changing from an office chair to an excise ball, or a couch and using that for 15 minutes to shift certain stress points to other locations on the body & spine. For the vast majority of people these will be more effective than just “sitting up straight”.

When I am treating someone with back pain, specifically associated with not moving (sitting) I make sure to release the main affected postural muscles. For low back pain; the hamstrings, glute and spinal muscles, for mid/upper back and neck pain; spinal, shoulder and arm muscles, combined with the advice described above, and self treatment techniques to effectively target and release to problem muscles for fast results.

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When to Worry About Back Pain.

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The bark of most back pain is worse than the bite, even when the pain levels are quite bad or even debilitating its usually nothing serious. Although for small percent of back pain suffers will have an underlying pathology or medical issue which is less than 3%. Without trying to oversimplify things most back pain felt stem from the soft tissues namely the muscles, although these are very often overlooked as a major contributor.

Things like MRI’s & x-rays a notoriously bad at diagnosing back pain when it comes bulging discs, arthritis, “alignment” etc… which were all previously associated with back pain in the past and often misleading. However, when I am treating someone for the first time or even over an extended period of time I always have in the back of mind and on the look out for anything that may indicate a more serious cause of their pain, such as autoimmune diseases particularly rheumatoid arthritis or other autoimmune arthritis, cancer, infections, fractures and several other culprits which may be a more serious cause of back pain.

This article is just to give you a very brief background in how to discern the difference between common musculoskeletal back pain and a more serious cause of your back pain. If you have any concerns its always best to see you GP or health practitioner such as a chiropractor or physiotherapist for a detailed assessment. It’s worth mentioning even more serious causes of back pain may not be painful and may fly under the radar at least at the beginning but usually becomes more apparent as time goes on. The level or intensity of pain overall is not a good indicator, but the type of pain and when it is or isn’t felt is often noteworthy. On the flip side you can have extreme back pain and it may be nothing more than a muscle spasm, I usually explain it to my patients it’s similar to having a calf cramp which is very painful but the cramp involves the muscles around your spine and can’t just be stretched out like a normal cramp.

Two symptoms or situations that require urgent medical attention is numbness around groin and buttocks with or without loss of bowel/bladder control. Or when you have experienced force from a fall or accident sufficient to cause a fracture, this may be falling of a ladder (even a low one), off a bike etc… even if pain levels are that high.

Three signs that need to be investigated further but not considered medical emergencies like the two example above.

  1. You have felt back pain for more than 6 weeks.
  2. If the pain has stayed the same or actually gotten worse.

(Both if these are even more important if you have been getting treatment.)

  • There is at least one coinciding “red flag from the list below”.

List of “ red flags” which are signs and symptoms of a more serious cause of back pain.

History of corticoid steroid use (especially important for fracture(s)

General signs of illness such as fever, chills

Unexplained weight loss

Family history of autoimmune disease, gradual but progressive increase of pain particularly before the age of 40 and unresponsive to treatment, significant low back stiffness in the morning, rashes etc..

“sciatic” like symptoms pain and needles and numbness in both legs, less of a concern if located in one leg.

Current or previous history of cancer.

So if you are experiencing back pain and you fit the description for potential serious cause of back pain it may be a good idea to book in to see your GP.

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Do You Suffer From Morning Back Pain?

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Back pain and stiffness in the morning is a common complaint I see in my practice, most people will state they wake up with pain and stiffness, get moving and have a hot shower then it will subside and then by the end of the day the pain and stiffness will return, it may also be the case it specifically is only felt for the first 30-60 minutes then completely fine for the rest of the day until the next morning. There are two main reasons why back pain first thing in the morning occurs, a more serious but less common cause and a less serious but much more common cause.

Serious But Less Common Cause

Inflammatory back pain (IBP) which is usually a result of auto-immune arthritis (not to be confused with osteo-arthritis) such as rheumatoid arthritis can include symptom of morning back pain and stiffness. This type of pain will usually wake the person up rather than feeling pain and stiffness once you are up and moving. The reason why pain is felt in the morning is not very clear but may have something to do with the body’s natural inflammatory circadian rhythm.

Other indications of IBP include more widespread pain in other joints such as hands, wrist feet, a family history of auto-immune arthritis, a recent infection and respond well to anti-inflammatories. Imaging such as x-rays, MRI and blood tests are required to confirm.

Not Serious but Much More Common

Myofascial or muscle pain is by far the most common reason for morning back pain and stiffness. It is usually a result of deep tightness and trigger points that run a good portion of the lower and lower mid back namely the erector spinae muscles. Typically the is no pain until you actually get up and start moving and putting on your shoe’s and socks can be a chore and it usually settles down fairly quickly, especially after having a hot shower as this increases blood circulation which allows the muscles to relax. Typically the trigger points are still there so as the muscles are being used throughout the day they can fatigue and tire quicker and the stiffness and tension will return later in the day.

I have treated hundreds of these over the years and assuming it hasn’t become too chronic or the muscles are not too deconditioned it is a very easy fix and usually only takes a couple of sessions. As the trigger points can be quite deep in the muscles a strong, deep tissue massage to the erector spinae muscles is what is usually required. Also doing self treatment/trigger point release using a tennis or lacrosse ball will greatly speed up the process and make sure it doesn’t come back anytime soon.

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Your Best Chiropractor in Sydney CBD – Why I Don’t Do Ten Minute Treatments

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Patients who have experienced this sort of 10-minute treatment before they come to me frequently state that they got the impression the practitioner was focused more on treating them quickly and having them come back frequently,often requiring treatment several times a week (which is absolutely not needed) or experienced little in the way of relief even though they’ve had 3 treatments.

Its highly unlikely to be able to provide quick & fast relief of chronic pain in just 10 minutes and not possible to correct posture without addressing the muscles as its the muscles which are responsible for holding the skeleton in an upright position and not the other way around. In fact, in my opinion the idea of fixing posture it is often used as marketing ploy to justify charging up to $70 and leaving people more willing to pay for such a short amount of time. 

Being a chiropractor myself, its sad to say that there seems to be a particular problem with other chiropractors putting profits before patients; it’s deeply frustrating to read research demonstrating that chiropractors on average see patients 4.5 times more often than an osteopath and 2.5 times more than physiotherapists. This research was undertaken in Australia, by chiropractors themselves, employing health fund data.

I believe that chiropractic treatment is the most effective when properly employed. However, 10-minute sessions, inevitably offering the same treatment independent of what the patient actually needs, treating six patients per hour and possibly more than 50 each day and geared towards the greatest profit.

 
 
 
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Weak Core, Pilates and Back Pain.

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There is usually not a week goes by where I am seeing a back pain client for the first time and they tell me they think their pain is because of a “weak core”. The fact is, the whole concept of a weak core and its relationship to back pain is dubious to say the least. It mainly stems from research done in the 1990’s by Australian physiotherapists which showed a delayed onset to the firing of the core muscles namely the transverse abdominus (Tra) in people with low back pain. This has spawned a massive industry of mainly physiotherapists, Pilates instructors, personal trainers telling their clients to brace their core by, “pulling the belly button towards the spine”, or “sucking the stomach in”, in an attempt to prevent or relieve back pain.

The idea of the core being a corset of muscles that stabalise the spine is anatomically incorrect, as the body is integrated with a 3D movement system that involves a large variety of muscles and connective tissue that span many parts of the body to control movement of the spine. The biggest issue with the idea of bracing or tensing the spine is the vast majority of people I treat already have quite tense/overworked back muscles, stiff spines, poor movement patterns and heightened fear avoidance behaviors I’m not sure what the goal of bracing the spine actually is. Stuart McGill a Canadian world leader in spinal biomechanics research say’s pulling the stomach in/hollowing may actually weaken the spine.

Another thing to note is most people feel back pain and stiffness first thing in the morning or when sitting for extended periods of time. There is no reason why a weak core would cause back pain under these circumstances as there is very little force on the spine, whether a core is strong or weak is not an issue. Also sitting while bracing your core would feel extremely unnatural and potentially aggravate the problem.

More than likely the delayed onset of firing of the core muscles found in the research the original research has more to do with the response of pain as a neurological coping mechanism to avoid low back pain rather than the other way around. Pilates is probably the biggest proponent of bracing the core or sucking in the stomach with instructors and physiotherapist a like charging exorbitant fee’s for classes when in fact you would more likely benefit just as much if not more from general exercise such as resistance training, swimming, yoga etc… With a recent systematic review finding; There is low- to moderate-quality evidence that Pilates is more effective than minimal intervention with most of the effect sizes being considered medium. However, there is no conclusive evidence that Pilates is superior to other forms of exercises. When you consider you can do other forms of exercise for free or comparably at very low costs with similar if not better results for lower back pain, pilates or doing endless plank exercises may not be the best choice.

kieranfWeak Core, Pilates and Back Pain.
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Is Cracking Your Own Neck Bad?

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This is something I get asked quite often, and generally speaking cracking your own neck is likely not causing any damage to the joints or the surrounding muscles. However; the issue is you shouldn’t actually feel pain or tension resulting in the urge to regularly twist, rotate and stretch your neck and get the associated audible popping or cracking sound for relief.

A result of the joint cracking is a signal being sent to the spinal cord where pain is processed and inhibits pain there. However, its usually the muscles which are tight, this restricts blood flow causing lactic acid to develop, which then stimulates the free nerve endings in the muscles (pain fibers outside of spinal cord). The joint cracking produces a sudden but usually short term pain relief at level of spine where it is processed but not originating from, the originating pain from the muscles overrides it and the urge to crack returns as pain is continuously been sent from the muscles, it becomes a painful and frustrating cycle of cracking, short term relief, cracking etc…. The neck pain suffer’s who feel the urge to regularly crack their own neck will greatly relate to this cycle.

The type of tightness is usually a result of long term stress and long term restriction in blood supply. There is what I can only describe by feel as gristle that develops in the tissues and by physically reducing the gristle with techniques I have refined over the years working at specific directions across the ‘grain’ of the muscle fibers (see diagram above) and returning proper blood supply not only does the feeling of needing to crack their own neck but also neck pain in general and associated headaches can be relieved quite quickly despite it being a chronic condition and that many other therapies have been able to provide relief for. I have also developed a technique or “homework” so pain suffer’s can effectively treat their own muscles.

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Migraine Treatment (Part 2)

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Introduction

In this article I will go through 2 groups of commonly used medications, however; its important you see a medical practitioner such as a GP for specific information for your individual needs. When used correctly under the proper supervision prescribed medications can be effective in preventing , lessening the severity and/or reducing the frequency of migraines. I will also go in to detail of non medication alternatives. It may be necessary a holistic approach that combines different treatments may be more effective than either one on its own.

Acute Medications

As I mentioned in my previous article, there are several phases of migraines which include the predome phase which includes symptoms prior to the attack such as Fatigue, light sensitivity, neck tension and stiffness, irritability, yawning, food cravings, difficulty sleeping, feeling unsettled etc… It is usually recommended not to take this group of medications during the predome phase but to wait until the attack to occur. The reason for this is because if used too frequently and/or in combination with other pain relief medication can lead to medication overuse migraines. It’s important it is only reserved for when absolutely necessary and other non medication options have failed to prevent the attack.

Preventative Medications

There are several types of preventative medications on the market and are the latest medications to be developed. They work by blocking receptors in the area’s of the brain which chemicals attach to that cause a migraine. They are generally taken once a month and by injection. It is usually only prescribed if you have 15 headache days a month, 8 of which are migraines and the migraine suffer have failed 3 other types of medications to prevent a migraine. They typically do not cause medication overuse migraines and tend to increase effectiveness the longer the sufferer is using them.

Non Medication treatments

It’s important to look at 2 or 3 days prior to the commencement of the symptoms to see if there are any commonalities that may not be so obvious, a migraine diary may be very useful in that regard. Not only recording the intensity/length/frequency/location of the migraine but mood/stress levels, sleep patterns, foods/drinks consumed, for females noting time of menstrual cycle, weather, medications.

In my experience stress is one of the most common triggers that cause a migraine, it could be worth while making a list of things that cause undue stress and tension and work out a plan to reduce those, counselling or psychotherapies may help, yoga, regular exercise, meditation or simply increasing your leisure time and doing things that you enjoy.

I have found treating the muscles generally of upper back, neck, shoulder, scalp and temple usually provide the best results and more specifically the levator scapula which attaches to the shoulder blade and the vertebra of the upper neck as well as the sub-occipitals which are small muscles that connect the neck to the skull are the biggest culprits when it comes to neck and muscle tension as a triggering factor for migraines. It is usually best to get treatment prior to the attack.

kieranfMigraine Treatment (Part 2)
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Migraine (Part 1)

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Migraines effect 12% of the population, I have seen it reported as high as 20%. Typically migraines tend to effect females more than males, it can be a regular occurrence or sporadic and infrequent. Typically it can be difficult to distinguish between a very severe headache and a migraine, however there are certain factors or symptoms that may help distinguish between the two. There are 4 phases when it comes to migraines.

Predome or Premonitory phase

Fatigue, light sensitivity, neck tension and stiffness, irritability, yawning, food cravings, difficulty sleeping, feeling unsettled to name a few. These can occur up to 72 hours prior to the actual migraine attack. It may seem strange that these symptoms are in fact related to migraines, the reason for this is because, migraines are a neurological condition happening at the level of the brain and specifically in area’s that control things like sleep, hunger, mood levels etc.

Aura Phase

Only about 30% of people who suffer from migraines will get an aura. Aura’s are reversible neurological symptom, although there are several different types of aura’s the most common is visual disturbances such as blurred or spotted vision. Other types aura’s include sensory, language and motor.

Attack Phase

This is the phase when people will get the headache, it tends to be one sided and felt at the base of the skull, side of the skull and eye and forehead. Its felt as a throbbing sensation and maybe accompanied by nausea/vomiting, sensitivity to light, smell and noise. This phase can last up to 4-72 hours.

Postdome Phase

This is usually felt as a headache, neck pain and stiffness, depression, fatigue after the attack phase has subsided.

Triggers

There are a variety of triggers, it is vital to be able to distinguish the trigger that are unique to you and the symptoms described in the predome phase. Triggers include emotional stress, hormones, not eating, sleep disturbances, neck pain, alcohol, bright lights, smoke, foods, exercise.

Although medications can be effective in dealing with migraines, there is the potential for migraine sufferers to get rebound headaches from overusing such medications and it becomes a viscous cycle of taking them to relieve a migraine while at the same time it is what is causing them. I will go in to greater details of medication induced migraines and other treatments in my next article.

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Does Sitting Cause Low Back Pain?

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Does Sitting cause low back pain? This may seem like such a clear and obvious question, especially for those who tend to get their back pain specifically sitting for any length of time. However, recent research that looked at 41 studies on the matter found that sitting is not a factor and there is an absence of a relationship, with no association between prolonged or occupational sitting and lower back pain. I must admit I was quite surprised when I saw the results as I would have said, in fact I have said in the past with a fair degree of certainty that sitting is a major cause of back pain.

Although I did find some of the researchers comments quite interesting, he stated people who sit for long periods of time may get muscle tightness, which could be a factor in why someone feels pain, most pain is felt in the muscles especially the superficial muscles that support the spine. So sitting and pain are not directly related but may be influenced by other factors such as pre-existing muscle tightness. Most people I treat rarely have low back pain when just sitting, they may also also feel it on certain exercises, movements, first thing in the morning etc… Indicating sitting in of itself is not the cause but more likely the effect. In any case it should be reassuring that sitting does not damage your spine or discs and looking at you muscles and other factors could be more worth while.

Finally, it is worth mentioning people who get regular general physical activity have lower levels of back pain and other chronic health conditions such as heart disease, diabetes and some cancers so it is still important you keep active not only to help prevent low back pain but improve overall health.

https://www.deakin.edu.au/about-deakin/media-releases/articles/deakin-mega-study-shows-sitting-not-so-bad-for-back-pain

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