Wednesday, September 24, 2014

Wisdom Wednesday: Chronic Low Back Pain

This new patient has been suffering from left sided sciatica for three months. About six weeks ago, he was hospitalized and treated for sciatica. During the hospital stay, he developed a perforated large intestine and had surgery, removing about a foot of large intestine and installing a colostomy bag. Subsequent surgery to remove the colostomy bag was successful. However, he developed C. difficile as a result of antibiotic therapy. After a few weeks, they were able to control the diarrhea well enough to send him home. He still has radiating pain down his left leg, his bowels are still inflamed with frequent diarrhea, and he now notes body wide aches.

Compare this history with the case of acute low back pain from last week’s Wisdom Wednesday. Obviously, this case is much more complex. On reviewing his history, he describes the pain as running down the anterior aspect of the left leg to the knee with occasional radiation into the groin. This is not the course of the sciatic nerve and, in fact, he was suffering from femoral neuralgia rather than sciatica. I have no clear information on the cause of the perforated intestine. However, I do comment on the relationship between these illnesses in my conclusions.

C. difficile kills about 1600 people in the US each year as the result of electrolyte imbalances associated with the diarrhea. It is an opportunistic infection that overgrows following the use of antibiotics. Please see my blog “Serious Diarrheal Infection in Kids Linked to Antibiotics” posted on March 14, 2014. Adults commonly develop C. difficile during hospital stays.

QA evaluation revealed impairment of Autogenic Facilitation (AF). Therapy Localization (TL) was to the surgical site of the perforated colon. This was corrected by Injury Recall Technique (IRT) restoring AF. Testing for inflammation was negative for prostaglandins, leukotrienes, cytokines, and histamine. However, nitric oxide was positive with a good response to L-glutamine, a particular probiotic (Saccharomyces boularidii), and folic acid. Challenge of the ilio-lumbar ligament was positive on the left, and after IRT correction, it returned again in weight bearing. TL was positive to the L4 vertebra, but no manipulation was performed.

He was placed on L-glutamine (to reduce inflammation of the gut), folic acid (to facilitate repair of the gut) and Saccharomyces boularidii (to displace the C. difficile) and was scheduled to return in two weeks.

On his second visit, two weeks later, the patient reported good reduction of his digestive issues. His widespread body ache has also improved radically. However, his left leg pain is unchanged.

AF was intact (no body wide injury) but leukotriene inflammation was indicated. Nitric oxide inflammation tested negative as did folic acid, but L-glutamine testing remains positive. Challenge of the ilio-lumbar ligaments remains positive on the left, only in weight bearing. He was open to manipulation today, so adjustments were performed at the T10 and L4 vertebrae. Ginger was added to the supplements to reduce leukotriene inflammation and he was scheduled to return again in two weeks.

His third visit occurred as scheduled in two more weeks. He reported a good reduction in left leg pain. His digestive issues and body wide aches have totally resolved. He has returned to swimming daily, using pull buoys as I recommended. He still has some leg pain if he tries to kick while swimming and he still feels a little vulnerable.

AF was intact but prostaglandin inflammation was indicated. Both leukotriene and nitric oxide inflammation tested negative. Direct challenge of L-glutamine remains positive. Challenge of the ilio-lumbar ligaments was negative.
Manipulation of L4 was repeated. He is to continue the L-glutamine, stopping the folic acid and probiotic as he runs out. He will substitute fish oil for ginger to reduce the prostaglandin inflammation. Slowly, he will add kicking to his swims as tolerated. He will return again in one month.

Bottom Line – Chronic low back cases require ongoing attention to all the factors – neurological status, inflammation, localized injury reflexes, mechanical stability, and gait. This case illustrates several classic findings in chronic low back pain:

  • The neurological injury resolved with one IRT treatment.
  • The pattern of inflammation was variable and ever changing. First it was nitric oxide, then leukotriene, and finally prostaglandin based. Each time supplementation had to be altered to properly address inflammatory factors.
  • The localized injury reflex in the ilio-lumbar ligaments was recurrent. This is the most important factor in resolving chronic low back pain. The constant firing of these nociceptors is the cause of chronic low back instability in most cases.
  • A careful history is vital to an accurate diagnosis. He was originally misdiagnosed as having sciatica. The perforated intestine, femoral neuralgia, and TL to the large intestine rather than the back or nerve lead me to believe that his large intestine was the issue all along. The femoral neuralgia was all referred pain. However, left untreated, it developed enough inflammation that it was ongoing even when the bowel issue resolved.
  • Finally, he resolved with minimal treatment because there was no nerve damage. Once the patient has true neuropathy, the healing response is limited.

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