Monday, November 20, 2006

Redefining Lower back pain, Sciatic Pain and other Symptoms in the lower kinetic chain, a mechanical definition

Lower back pain is a condition that costs Billions per year to treat, yet, treatment has been inconsistent at best, it misunderstood at worst and has been treated with varying levels of success. One of the most studied groups with the most consistent results has been chiropractors, followed by Physical Therapists, followed by medical treatment which includes surgeries and medication.

The problem with back pain definitions to this point is that the symptoms are what are defined, and then treatment is based on the symptoms. Unfortunately, back pain, sciatica and even knee pain are caused by malfunction of the lower kinetic chain (the series of joints including the ankle, knee and hip, with secondary effects on the shoulder, elbow and wrist), asymmetry and inherited traits which allow for either efficient or inefficient mechanics resulting eventually in breakdown we see as pain, sciatica, arthritis, worn out knee or hip joints and secondary effects into the upper body in the neck, shoulder, elbow.
Poor mechanical function results in muscular breakdown, poor firing patterns (groups of muscles that work together to achieve movement around a joint. A poor firing pattern results from shortened and weakened muscles that do not generate enough force to move as joint properly, requiring the body to recruit surrounding muscles into the action, causing an area to tighten). It is the author’s opinion that most herniated discs in the lower back and neck, are caused by asymmetry in the way the joints are moving when a person is built asymmetrically. This type of body style will impart shearing forces to these joints creating a process called creep (take a piece of plastic, keep on bending it until it begins to break is what we call creep). Creep will cause discs to fail and degenerate due to abnormal wear and tear. Promotion of symmetry will help avoid this process.

Many researchers such as Vladmir Janda, Brian Rothbart and many others have worked with kinetic chains, function or malfunction. Rothbart had shown in his engineering model how the body implodes or rolls anteriorly the more the feet flare out (overpronation of the feet). Many of my own articles discussed a concept called the basic pronation accommodation pattern that explains what happens with this implosion effect to the muscles and ligamenture.

Buried in all this information that has been published over the years is a most appropriate definition which is of a mechanical nature.

Back pain, Sciatica, Knee Pain, Lumbar Disc problems are a function of gait. The more efficient and symmetrical this persons body style is, the more likely they will experience chronic back, leg, knee and hip pain and secondary problems in the upper body.

The more the foot flares out, the more the knee rolls in (see If you have one leg that either turns out or in as compared to the other, the leg that flares out will create a functional short leg and will act as if it is shorter than the other leg. This causes an effect called pelvic unleveling. The side that flares out will also tighten up over time, with most of the muscles in the lower kinetic chain involved. This will cause movement of that side to become inefficient and this leg will eventually tighten in the back, creating tightness into the hamstring. The body will compensate with the quadriceps and psoas muscle (main mover of hip and strongest muscle in the body) to tighten on this side. This torque on the pelvis will lead to lower back pain, inflexibility of the legs which will in turn reduce the flexibility of the person who has this type of mechanics and sacro iliac or garden variety back pain. The pain is caused by the side of overpronation locking up and the opposite side straining. Typically, the side of strain is the side of pain in sacroiliac pain syndromes. The longer this persists, the tighter the quadratus, erector and multifidii muscles get creating further reduced mobility and upper kinetic chain malfunction which is why tight hip flexors will cause neck pain as this condition locks up and in the worst cases rotates the rib cage to the side of overpronation, often producing pain in the shoulder blade on the opposite side.

As you can see, body style produces lower back pain and many other problems chiropractors have successfully treated.

Intelligent treatment of gait issues begins at the feet. This includes eliminating flat shoes and wearing foot orthotics which have proven beneficial in improving the efficiency of body mechanics. A good doctor will look at body style, evaluate the symptoms and have an understanding of cause and effect. Treatment shall include myofascial release or similar method to improve muscular efficiency, improve firing patterns and promote body symmetry. Exercises should be performed to enhance the effect of myofascial treatment and strengthen released tissues. The role of orthotics should be explained in layman’s terms to the patient, and they need to recognize that these inserts need to be part of their lifestyle. Secondary effects of treating body style issues will be improvement in the way the upper body functions, fewer problems in the upper kinetic chain (shoulder, elbow and wrist) and improved ability to move their neck.

Herniated discs are a function of this system going bad. Since the body does not tolerate asymmetries, asymmetries in gait will cause shearing forces in the gait cycle resulting in a process called creep. Creep is structural fatigue (not dissimilar to taking a piece of plastic and bending it until it develops cracks). Since asymmetries will cause excess motion and wear and tear at the joints, eventually, the material (annulus fibrosus) can fail and cause the disc material to either bump out (bulge), herniated (break through inner but not outer fibers, extrude (break through the outer surface) or become an extruded segment (disc material in the spinal canal requiring surgical intervention).

Improving body mechanics using intelligent treatment will likely decrease ones likelihood for herniated discs, knee problems, sciatica and many upper back conditions.

While this is not your standard definition, it will lead to more intelligent treatment. Since back pain is a gait issue as I have shown, treating it as such yields more reliable results. Perhaps, this is why some chiropractors are able to yield better outcomes for the condition (most studies support this).

Thursday, November 2, 2006

Fighting the good fight

One of the most frustrating things for a doctor, any doctor in this current health care environment is dealing with managed care companies. Many fine physicians, from my neurosurgeon, to others have actually opted out of the managed care networks either partly or altogether because of either underpayment, non payment of approved services or burdensome paperwork requirements that do not improve the quality of care, but does increase the stress level of the practitioner.

The other day, a long time practicing chiropractor I know who has helped thousands over the years and was the treasurer of our chiropractic sports council did the ultimate in opting out. He left the profession for good. Knowing what todays practice environment is like, it is really tough to stay in practice with the attitude of wanting to help others because the insurance companies and their cronies such as american specialty health, ACN group, Landmark Healthcare and others have increased the stress and paperwork on chiropractors while decreasing their reimbursements. Imagine if every year your employer had you work more hours, had you fill out paperwork to justify your very existance with the company and then instead of paying you more, paid you less with the money that you should have earned going to a company whose sole purpose is to dehumanize patient care and make another department wealthy at your expense.

This is what it is like to practice today. I may sound negative but these are todays realities. The other day, a month after filing an appeal, we received notice that ACN group has officially terminated us from United Healthcare as of December 2006. The reason for this had little to do with quality of care, but with cost. We have a specialty practice that handles many complicated myofascial issues and the visits may be longer than the quickie treatment they would like to see and although we are in line visit wise, our costs are higher. Their solution is three tiers. First tier is non limiting. If you don't reach their financial goals through downcoding yourself voluntarily (charging them for the minimum even when you do the maximum), they then put you in the second tier in which they limit your visits and fill you with continued extra streams of paperwork. When this fails to do what the first tier did, they then send you a contract to shape up or get kicked out. Since they do keep stats (not sure how they did because up until recently, so few of our patients required their paperwork), they used these stats against us and asked us to see our profile on line on a quarterly basis. In other words, keep your numbers low, irregardless of what you do in your office or your're out. We did make a conscious effort to improve our numbers and they did improve, but apparently not enough.

Our stay in the network has been further made uncomfortable by their auditing of certain patient files (they want the power to ask for money back if you forgot to note something even if you performed the service), they are downcoding from what we are doing on claim payments (causes cash flow shortages and we cannot budget monthly expenses and it of course if illegal), they are misinforming us as to who needs to be precertified, and then ignoring the proof showing it is their fault, not yours. This makes us crazy because they then tell us to send it to second tier review. All this does is increase practice stress and drives us crazy. They also deny the first visit if you dont file paperwork, even if the person only needed one visit. If this sounds like they are trying to dehumanize our profession and create unnecessary angst, it is what it sounds like and from what the American Chiropractic Society tells me, they have dismissed about 1/3 of their doctors from their network nationwide. After hearing all this, why should I want to be in network? The more I think about it, out of network is sounding better and better.

Although being in network has its appeal, many of our united clientele will likely stick with our office because we provide a level of service that is difficult to find in the chiropractic arena in our area. We will also be reimbursed at a better level out of network as well and likely be able to totally avoid the ACN paperwork.

From what I hear, there will be a lawsuit. ACN is owned by United Healthcare. United Healthcare continues to bully doctors around. Recently, we were told that if we did not agree to voluntarily get electronic statements, they will do it for us and then gave us a deadline, instead of the typical mailed statement. This will save them millions in postage, yet your premiums are likely increasing for health care again this year with an increased co payment.

Getting back to the good fight: I wish to be able to practice in a free environment. Free to help others. Many are just slipping through the cracks in our healthcare system. We help many of them after their doctor sent them for tests that cost more than the care to resolve the condition. Yesterdays new patient was a perfect example of this. MRI, x rays of hip when his lower back and pelvis were twisted from a back sprain and it was clearly visable, all you needed to do was look at the person.

Not sure where to go after this but this gives you an idea of what it is like from the chiropractic perspective in the health care battlefield