Dynamic Chiropractic August 2018

Low back pain will affect some 80 percent of all adult Americans at some point.(1) However, it’s not just an American problem. Low back pain is becoming more prevalent around the world. Worldwide, disability from low back pain has risen by more than 50 percent since 1990.(2)

As low back pain becomes a more international problem, the costs to patients, health care systems, and society escalates. In the U.S. alone, total costs associated with LBP exceed $100 billion per year, two-thirds of which are a result of lost wages and reduced productivity.(3)

Drugs Don’t Help

Traditional medical treatment of low back pain often involves prescription painkillers, particularly opioids. The risk of abuse and addiction with these drugs is well known. In 2016, the CDC issued revised prescribing guidelines that recommend sharply cutting the duration of any pain-killer prescription.(4) Most importantly, these drugs fail to be effective in the long term.

A 2016 meta-analysis of 20 studies of opioids for low back pain, published in JAMA Internal Medicine, found that opioid analgesics for chronic low back pain provided only modest short-term pain relief, and only for some patients. In many of the studies analyzed, more than half of the participants in the trial dropped out due to adverse side effects of these dangerous drugs. None of the studies showed clinically important pain relief (defined as more than 20 points improvement on a 100-point scale). Those who did get some relief from pain took doses that were much higher than recommended.

The meta-analysis brought out an important point about opioid studies: almost all are short term. Very few high-quality studies have looked at the long-term effects of opioid use for patients with chronic low back pain. A recent study that did look at a 12-month period found that treatment with opioids was no better than treatment with nonopioid medications such as ibuprofen for improving pain-related function.(5)

In addition to offering little help to patients, opioid drugs can make chronic pain worse. For some patients, using opioids can induce hyperalgesia, or a paradoxical response whereby patients who take these drugs become more sensitive to painful stimuli. The mechanisms behind hyperalgesia are still unclear, but the risk that painkilling drugs could make a patient more sensitive to pain is clear.6 Hyperalgesia is another potential harm to add to the long list of bad side effects of opioid use.

Better Solutions

The evidence is very clear: opioids not only aren’t a solution to low back pain, they’re harmful to patients and may make the pain worse. Nondrug treatments, such as nonthermal low-level laser therapy led by chiropractors, are far preferable. They’re safe, they’re supported by research, they work, and they’re cost effective.

A Breakthrough Tool For Chronic Low Back Pain

In July 2018, the Erchonia FX 635 low-level laser received official FDA clearance for relief of chronic low back pain—the first and only laser to be cleared for this purpose. Chiropractors now have a powerful new tool to help their patients relieve chronic low back pain and get back to work and normal activity.

Founded in 1996, Erchonia is the first company in the world to gain an FDA market clearance for the use of low level laser therapy. The company has 16 FDA 510(k) approvals for their equipment and more Level 1 clinical trials than all other therapeutic laser manufacturers combined.

The clinical trial conducted to obtain FDA clearance was designed to test the effectiveness of the Erchonia FX-635 in providing relief of chronic low back pain of musculoskeletal origin. The study was a placebo-controlled, randomized, double-blind parallel group multi-center design.

Fifty-eight people completed the study; half were treated with the laser and half were treated with a placebo (sham laser 635nm LED). All the participants rated their pain as 40 or greater on the 0 to 100 Visual Analog Pain Scale (VAS). The average duration of low back pain for the participants was 97.8 months (approximately eight years). The majority of the participants had had bilateral low back pain with an average pain rating of 59.10 on the VAS.

All the participants received eight 20-minute procedure administrations across the lower back region with the Erchonia FX-635 laser (active or sham) across a four-week period: two procedures per week, each procedure three to four days apart.

Of those who received the active laser treatment, 72.4 percent attained a 30 percent or greater decrease in chronic low back pain VAS rating from baseline to endpoint (see chart).

Chart 1 shows the response to laser treatment among the test group and those who received placebo treatment (635 nm LED, not a laser). Among the actual treatment group, VAS ratings dropped precipitously from 59 to 23 over eight weeks. Among the placebo group, the drop was only about 10 points and the improvement quickly leveled out.

No adverse events were reported during the study duration. At the end of three months, the reduction in pain was sustained, even though no additional treatment was administered after the first month.7 Low level laser treatment (LLLT) works by stimulating cell activation processes which, in turn, intensify physiologic activity. The light energy from the laser initiates a cascade of reactions that stimulate the mitochondria to increase the production of ATP. The laser light stimulates the release of natural healing chemicals that lead to rapid cell growth, increased metabolic activity, increased angiogenesis, improved vascular activity, suppression of the COX-2 inflammatory pathway, and decreased inflammation.

The specific wavelength (color) of the laser light is responsible for influencing the biochemical cascades. Research has shown that a wavelength of 635 nm is ideal for accelerating healing and reducing post-injury inflammation. The coherent, pulsed light delivered by the Erchonia laser insures deep tissue stimulation and absorption.

Laser treatment is painless. There’s no sensation of heat and the skin and tissue aren’t damaged in any way. The patient lies prone; the laser light is provided by the FX-635 using three diodes on an adjustable stand. The laser light is delivered to the lower back area in a moving circular pattern for twenty minutes. The patient does not need to be attended during this time.

The clearance of the FX-635 is a watershed moment for the chiropractic profession for treating low back pain.

(Erchonia Corporation www.Erchonia.com)

https://www.drrobertsilverman.com/

REFERENCES:

1. Lemeunier, N, Leboeuf-Yde, C, and Gagey, O. The natural course of low back pain: a systematic critical literature review. Chiropract Man Ther. 2012; 20: 33

2. Stephanie Clark, Richard Horton. Low back pain: a major global challenge. The Lancet. Volume 391, No. 10137, p2302, 9 June 2018. DOI: https://doi.org /10.1016/S0140- 6736(18)30725-6 |

3. William Thomas Crow, DO; David R. Willis, DO, MBA. Estimating Cost of Care for Patients with Acute Low Back Pain: A Retrospective Review of Patient Records. The Journal of the American Osteopathic Association, April 2009, Vol. 109, 229-233.

4. Deborah Dowell, MD; Tamara M. Haegerich, PhD; Roger Chou, MD. Morbidity and Mortality Weekly Report (MMWR), CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016; March 18, 2016, 65(1);1–49.

5. Krebs EE et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients with Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018 Mar 6;319(9):872-882. doi: 10.1001/ jama.2018.0899.

6. Lee M et al. A comprehensive review of opioid-induced hyperalgesia. Pain Physician. 2011 Mar-Apr;14(2):145-61.

7. Market Clearance to Treat Chronic Low Back Pain.(FX 635) – 2018 – A Placebo-Controlled, Randomized, Double-Blind, Parallel-Group, Multi-Center

Dynamic Chiropractic June 2018

Pain is a huge problem in America, and all Americans know that opiate drugs are not the solution to our pain problem. In her 2014 book, A Nation in Pain, Judy Foreman claims, “Out of 238 million American adults, 100 million live in chronic pain.” (1) A conservative estimate of the direct costs and lost productivity resulting from this pain is up to $635 billion yearly (2). Chronic pain affects every region of the body. Quantifying the anatomical regions for American’s chronic pain shows that the most significantly affected region is the lower back followed by (3):

Lower-Back Pain 28.1%

Knee Pain 19.5%

Severe Headache 16.1%

Neck Pain 15.1%

Shoulder Pain 09.0%

Finger Pain 07.6%

Hip Pain 07.1%

There is a high level of satisfaction by patients who seek treatment for spinal and other pain syndromes from chiropractors (4). It is argued that the physiological basis for the chiropractic benefit for pain suffers is the closure of the “pain gate.” (5) Yet, chiropractors often also use adjuncts to spinal adjusting for the treatment of pain syndromes. The rational for such adjuncts is that inflammation alters the threshold of the nociceptive system.

Most pain is a chemical event. Inflammatory chemicals irritate pain nerves. Understanding of the inflammatory chemical nature of pain was awarded the Nobel Prize in Physiology or Medicine in 1982. In 2007, the journal Medical Hypothesis states (6): 

“Every pain syndrome has an inflammatory profile consisting of the inflammatory mediator that are present in the pain syndrome. “The key to treatment of Pain Syndromes is an understanding of their inflammatory profile.” “The origin of all pain is inflammation and the inflammatory response.”

“Irrespective of the type of pain whether it is acute or chronic pain, peripheral or central pain, nociceptive or neuropathic pain, the underlying origin is inflammation and the inflammatory response.”

“Irrespective of the characteristic of the pain, whether it is sharp, dull, aching, burning, stabbing, numbing or tingling, all pain arises from inflammation and the inflammatory response.

Although there are many inflammatory chemicals related to pain, the best understood is an eicosanoid hormone-like chemical called Prostaglandin E2 (PGE2). As depicted in the graph above, PGE2 is derived from the omega-6 fatty acid Arachidonic Acid (AA). AA itself is derived from vegetable oils, primarily corn, soy, sunflower, safflower, cottonseed, peanut, and canola oils. As such, consumption of any of these vegetable oils is inflammatory and related to pain thresholds. When one consumes meat derived from animals fed any of these products one is consuming high quantities of pre-formed AA, increasing the likelihood of suffering from pain syndromes (7).

In the pain references text, Weiner’s Pain Management, published by the American Academy of Pain Management, it notes the following as a major cause of the modern epidemic of pain (8):

“Changes in the modern diet are largely responsible for the increasing incidence of essential fatty acid imbalances and deficiencies.”

“The ratio of omega-6 to omega-3 fats has changed dramatically due to the widespread use of vegetable oils (mostly n-6 fats) in cooking and to the processing of oils.”

“Historical estimates place the ratio of omega-6 to omega-3 oils at nearly 1:1 for prehistoric humans.”

By the turn of last century (1900), the ratio had increased to about 4:1. The current American ratio is about 25:1.

This text indicates that 100 years ago Americans consumed about two pounds of these inflammatory vegetable oils yearly; the current approximate level of consumption in 25 pounds yearly. The results are an explosion of inflammatory conditions, including pain, which are treated with non-steroidal anti-inflammatory drugs (NSAIDs).

As noted in the graph below on left, the conversion of the omega-6 fatty acid AA into inflammatory (and pain producing) PGE2 is controlled by a series of enzymes called cyclooxygenase, often abbreviated COX. The 1982 Nobel Prize details how the COX enzymes are inhibited by a group of drugs, mentioned in Weiner’s text, non-steroidal anti-inflammatory drugs (NSAIDs). However, when these drugs (NSAIDs) are taken for chronic pain, there are many serious side effects. In 2003, the journal Spine states (9):

“Adverse reactions to non-steroidal anti-inflammatory (NSAID) medication have been well documented.”

“Gastrointestinal toxicity induced by NSAIDs is one of the most common serious adverse drug events in the industrialized world.”

In 2006, the journal Surgical Neurology states (10): Blockage of the COX enzyme inhibits the conversion of arachidonic acid to the very pro-inflammatory prostaglandins that mediate the classic inflammatory response of pain.

Almost all patients who take the long-term NSAIDs will have gastric hemorrhage, 50% will have dyspepsia, 8% to 20% will have gastric ulceration, 3% of patients develop serious gastrointestinal side effects, which results in more than 100,000 hospitalizations, an estimated 16,500 deaths, and an annual cost to treat the complications that exceeds 1.5 billion dollars.

“NSAIDs are the most common cause of drug-related morbidity and mortality reported to the FDA and other regulatory agencies around the world.”

Other side effects attributed to the consumption of NSAIDs includes end-stage renal disease, heart attacks, strokes, erectile dysfunction, hearing loss, deep vein thrombosis, and increased risk of Alzheimer’s disease

A modern and proven effective non-drug approach to the treatment of pain, especially chronic pain, is the supplementation of omega-3 fatty acids, especially eicosapentaenoic acid (EPA), found in fish oil. EPA is a precursor to the anti-inflammatory eicosanoid Prostaglandin E3 (PGE3). The only drawback to this approach (supplementation with high-dose quality fish oil) is the optimum benefit takes months of ingestion (10, 11, 12).

Is there a way to inhibit the COX enzymes for the treatment of both acute and chronic pain that is quick, effective, and safe, without side effects? The answer is yes, the application on low-level laser therapy.

A search of the National Library of Medicine using PubMed (3/29/2018) with the search terms “low-level laser therapy AND pain” locates 1,161 citations. A search of the National Library of Medicine using PubMed (3/29/2018) with the search terms “low-level laser therapy AND NSAID” locates 66 citations. Laser Therapy reference texts emphasize the ability of low-level laser to effectively treat pain without side effects. For example, the 2010 book titled The New Laser Therapy Handbook states (13):

“The effect of laser photon therapy [LPT] on inflammation is covered in many chapters of this book. The anti-inflammatory effect of LPT has been widely studied. LPT seems to have a similar effect to steroids and NSAIDs, but without the severe side effects of these very common pharmaceuticals.”

The authors indicate that laser therapy for pain control is enhanced if the laser is applied to both the painful region and the nerve roots that innervate the painful region. Other studies further emphasize the importance of applying the laser to the nerve roots. A particularly interesting study resulted in the successful management of 35 patients suffering from carpal tunnel syndrome; the laser therapy was not applied to the wrist but rather to the nerve roots that innervate the wrist (14).

There are advantages to being capable of doing both regions simultaneously.

An important study documenting the ability of low-level laser therapy to inhibit COX enzymes resulting in a significant reduction in inflammatory chemicals was published not in a laser journal, but rather in a cancer journal, Support Care Cancer (15). After exposing animals to caustic inflammatory chemicals (fluorouracil), they were randomly assigned to either a control group (no laser) or to low-level laser therapy. At four time points, tissue samples were immunohistochemistry assessed from both groups by a blinded examiner. The authors found that the laser therapy group “was accompanied by a significantly lower level of COX-2 staining.”

Interestingly, increasing the laser fluence (increasing the milliwatts by 3X) did not further enhance the clinical outcomes. In contrast, such higher laser fluence reduced the clinical benefit to the level of the control group (no laser). This suggests that laser therapy is not linear, but rather hormetic (bell shaped curve). The authors concluded:

“The tissue response to laser therapy appears to vary by dose. Low-intensity laser therapy appears to reduce the severity of mucositis, at least in part, by reducing COX-2 levels and associated inhibition of the inflammatory response.”

Thousands of chiropractors are using low-level laser therapy as an adjunct to chiropractic and nutrition in the management of their pain patients. Low-level laser therapy is quick, effective, and safe, and earned FDA clearance in 2002. (Erchonia Corporation www.Erchonia.com)

www.DanMurphyDC.com

REFERENCES:

1) Foreman J; A Nation in Pain, Healing Our Biggest Health Problem; Oxford University Press; 2014.

2) Pho, K; USA TODAY, The Forum; September 19, 2011; pg. 9A.

3) Wang S; Why Does Chronic Pain Hurt Some People More?; Wall Street Journal; October 7, 2013.

4) Adams J, Peng W, Cramer H, Sundberg T, Moore C; The Prevalence, Patterns, and Predictors of Chiropractic Use Among US Adults; Results From the 2012 National Health Interview Survey; Spine; December 1, 2017; VOL. 42; No. 23; pp. 1810–1816.

5) Kirkaldy-Willis WH, Cassidy JD; Spinal Manipulation in the Treatment of Low back Pain; Canadian Family Physician; March 1985; Vol. 31; pp. 535-540.

6) Omoigui S; The biochemical origin of pain: The origin of all pain is inflammation and the inflammatory response: Inflammatory profile of pain syndromes; Medical Hypothesis; 2007, Vol. 69; pp. 1169–1178.

7) Hyman M; Eat Fat, Get Thin: Why the Fat We Eat Is the Key to Sustained Weight Loss and Vibrant Health; Little, Brown and Company, 2016.

8) Boswell M, Cole BE, editors; Weiner’s Pain Management: A Practical Guide for Clinicians; American Academy of Pain Management; Seventh Edition; 2006, pp. 584-585.

9) Giles LGF, DC, PhD; Reinhold Muller R; Chronic Spinal Pain: A Randomized Clinical Trial Comparing Medication, Acupuncture, and Spinal Manipulation; Spine; July 15, 2003; Vol. 28; No. 14; pp. 1490-1502.

10) Maroon JC, Bost JW; Omega-3 Fatty acids (fish oil) as an anti- inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain; Surgical Neurology; 65 (April 2006); pp. 326–331.

11) Cleland LG, James MJ, Proudman SM; Fish oil: what the prescriber needs to know; Arthritis Research & Therapy; 2006; Vol. 8; No. 1; 202. 12) Goldberg RJ, Katz J; A meta-analysis of the analgesic effects of omega- 3 polyunsaturated fatty acid supplementation for inflammatory joint pain; Pain; May 2007; Vol. 129; No. 1-2; pp. 210-223.

13) Tuner J, Hode L; The New Laser Therapy Handbook, Prima Books, 2010. 14) Wong E, Lee G, Zucherman J, Mason DT; Successful management of female office workers with “repetitive stress injury” or “carpal tunnel syndrome” by a new treatment modality–application of low-level laser; International Journal of Clinical Pharmacology and Therapeutics; April 1995; Vol. 33; No. 4; pp. 208-211.

15) Lopes NN, Plapler H, Chavantes MC, Lalla RV, Yoshimura EM, Alves MT; Cyclooxygenase-2 and vascular endothelial growth factor expression in 5-fluorouracil-induced oral mucositis in hamsters: evaluation of two low-intensity laser protocols; Support Care Cancer; November 2009; Vol. 17; No. 11; pp. 1409-1415.

Daniel Murphy, DC, DABCO is a well-recognized, award winning chiropractor and a popular instructor who teaches internationally while maintaining a part-time clinical practice. He has taught over 1,610 twelve-hour postgraduate continuing education classes. He also serves as part-time undergraduate faculty professor at Life Chiropractic College West, where he is currently teaching classes to seniors in the management of spinal disorders. He has taught post-graduate classes for a long list of chiropractic colleges and individual programs. He is a contributing author to several books and a quarterly columnist in the American Journal of Clinical Chiropractic. From 2003 – 2009, Daniel Murphy, DC, DABCO served as the Vice President of the International Chiropractic Association. In 2014, he was awarded the Lifetime Achievement Award from the International Association of Functional Neurology and Rehabilitation (IAFNR).