Spinal Manipulation for Herniated Disc

Clinical Evidence Handbook: Herniated Lumbar Disk - April 1, 2006 - American Family Physician

One of my more common complaints to come through the clinic doors is chronic low back pain with an acute exacerbation. Recently, I had a young healthy individual present with new onset low back pain after weight lifting when she heard an audible pop in her low back resulting in her left lateral leg tingling. Aside from decrease sensation along her lateral thigh, her physical examination was unremarkable.  She had full range of motion of her back and hips in all directions, mild pain with bending forward and increased tension along the left side of her back. Oddly, her symptoms were on the opposite side of her MRI findings which revealed a right disc protrusion affecting the right L5 nerve root.  The patient desires to return to exercising and is anxious about the thought of not being able to lift people for her work.

Herniated lumbar disc is a very common finding in patients with low back pain.  The use of aggressive treatment however is not always beneficial.  The only management course that has been shown to likely to be beneficial is spinal manipulation.  Improving mobility and stability above and below the affected area are likely to provide more lasting results than neurosurgery without the adverse complications.  Osteopathic manipulative treatment (OMT) utilizes spinal manipulation to improve the functioning of the spine by encouraging proper alignment.  Spinal mobility and stability doesn't rely on correct spinal alignment alone.  Balancing muscle tension and elimination of fascial strain patterns are also important in allowing the body to function well.  Core strengthening and retraining the body to move effectively are vital components to the healing process.

For many patients with chronic low back pain, the problem isn't a herniated disc but rather poor movement patterns.  Correction of these movement patterns and restoring the spinal strength and mobility should be the object of chronic low pain.

Charlie Horse Delays Game

High school football season has begun.  This is the 3rd year that I am assisting on the sidelines for the Charter Oak High School football team. After back-to-back championships, the team has moved up to Division 2 this year to compete against larger schools.  As a team physician, my job is to ensure that players are safe and healthy.

The third quarter of preseason game 2 seemed to take forever this year.  One athlete after another on the opposing team collapsed to the floor as they experienced a sudden intense pain in their calf. No tear, no trauma, instead a "Charlie Horse".  As the calf muscle involuntarily and forcibly tightens, the player in vain rubs his leg failing to relax it.  As we approached the third cramp, the players explained to us that "they don't like to eat their bananas."

Cramps are extremely common.  Athletes often suffer from cramps at the initiation of training when the body is not fully conditioned.  A combination of vigorous use of muscles resulting in muscle fatigue, inadequate stretching, and dehydration with sodium depletion appear to causes skeletal muscle cramps in athletes.

Muscle cramps are preventable.  Here are a few simple measures to avoid cramping during the season.

1. Train smart to avoid muscle fatigue.  During the preseason, emphasis on strengthening and conditioning muscles helps to avoid muscle fatigue.  Gradually increase intensity and frequency of the workouts to ensure proper stamina once season begins.  Allow for appropriate recovery of fatigued muscle and follow with step-ladder progression of the workout.  Utilize cross-training to avoid muscle fatigue by alternating muscle areas of focus during workouts.
2. Stretch warm muscles.  Prior to athletic performance, warm-up should simulate the activity expected but at a lower intensity.  Stretching should be performed once the muscles are warm.  The stretches should focus on areas that are maximally lengthened and contracted during performance.
3. Anticipate salt and water loss.  Sweat contains between 2.25-3.4 grams of salt per liter.  The rate of perspiration on a humid day of competition can easily average more than 1 liter per hour especially with full pads on.  As a result, replacement of fluids doesn't just imply drinking more water.  It demands consumption of salt-containing liquids to replace the salt loss in sweat.  Only drinking water while losing excess salt can result in hyponatremia which may manifest as nausea, cramps, headaches, weakness, confusion and if severe seizures and coma.  It is no wonder that the first commercial sports drink Gatorade developed in 1965 as response to improving performance in the Florida football team has become a huge success. 

Once a cramp has developed, these are a few suggestions for recovery.

1. Assist the athlete to a safe location.  Muscle cramps can last anywhere from a few seconds to a quarter of an hour or occasionally longer. As such, it is important to have the athlete quickly assisted to a safe area once the problem has been identified.
2. Passively stretch the cramped muscle.  With the calf cramp, lay the athlete on the back and raise the affected leg.  Stretch the calf by passively flexing the foot toward the shin while the leg is maximally extended.  Rhythmically stretch the calf as tolerated by the athlete until the cramp has resolved.
3. Encourage hydration and stretching.  A cramp is likely to return if the athlete does not recover properly.  Make sure the athlete continues to stretch the muscle and replace fluid loss during the rest period.