Wednesday, September 17, 2014

Wisdom Wednesday: Acute Low Back Pain – A Brief Case History

This is the first in a series of typical case histories taken from my office notes. They will appear in the Wisdom Wednesday blog slot intermittently. I hope they will give the reader some insight into managing and guiding a patient through a health issue.

A 66-year old female returns to my office for the first time in six years with complaints of acute low back pain. She has been struggling with chronic bilateral knee pain and has had a couple of orthopedic opinions on treatment ranging from medication management to total joint replacement. She denies radiating pain from the back to the legs and believes the onset is related to compensating for the knee pain. She is currently on the following medications: Atenolol, Celexa, Benacar, Zyrtec, Eliquis, Prempro, Simustatin, Armour Thyroid, Flecainide and 2 baby aspirin per day. (The average American takes 4 prescription medications daily, so this patient is taking twice that amount. I commonly see patients taking 16 different prescription medications on a daily basis).

Autogenic Facilitation (AF) was intact, using a weak left gluteus medius as an indicator muscle. (This indicates no body wide injury response by the nervous system. Her body has either resolved the injury neurologically, or there was no body wide injury stimulation to begin with - the later fits her history) Oral challenge with a mix of NSAIDS resulted in strengthening of the weak muscle. A favorable response to oral challenge with fish oil was noted. (These tests indicate that her primary inflammatory response is the production of prostaglandins despite taking aspirin daily which tends to block this pathway) Challenge of the left ilio-lumbar ligament was positive in weight bearing only, corrected by Injury Recall Technique (IRT). (This is a local injury reflex and is the most common source of ongoing neurological stimulation in low back pain) Gait assessment was intact. (Despite her contention that this low back episode is the result of compensating for her knee pain, no altered gait mechanism was indicated)

Articular fixations were noted at the L5 vertebra with moderate muscle spasm from the lower thoracic spine to the pelvis. Manipulation of the L5 and T10 vertebrae was performed with an audible release. She was instructed to take 4 pearls of fish oil daily with meals to reduce prostaglandin inflammation and return in a week if symptoms persist.

She returned 5 days later reporting that she had excellent temporary relief for 3 days following treatment, only to have the pain return without apparent cause, over the weekend.

AF was again intact. However, oral challenge with NSAIDS resulted in global weakness. A favorable response to ginger was noted. Challenge of the ilio-lumbar ligaments was negative and no gait mechanism was found.

The articular fixations and manipulations performed with unchanged – L5 and T10. I reduced the fish oil to 2 per day and added ginger to reduce leukotriene inflammation.

She returned again six months later with an unrelated health issue. Her low back has been pain free since her last visit.

There are five factors to evaluate and balance in treating low back injuries – neurological status, inflammation, injury reflexes, spinal mechanics, and gait mechanisms. In acute low back pain it is usually the inflammation or injury reflexes that delay or prevent healing. Although she had excellent initial results from care, her inflammatory process switched from prostaglandins to leukotrienes. This is probably the result of daily aspirin use. So the fish oil was quickly ineffective at reducing her inflammation. Despite resolution of the localized injury reflex, she did not hold her adjustment and all her pain returned. Switching to ginger was effective at reducing the inflammation and repeating the adjustment allowed the spinal mechanics to return to normal. If you want to know more about prostaglandins and leukotrienes, please review my blog “Inflammation – Part 1” posted on March 19, 2014.

Finally, I am amazed at how well she responded to conservative care given all the medication she is taking. Her chemical pathways are markedly impaired and I am convinced the drugs are creating more harm than benefit.

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