A wretched back

These letters exemplify many that I have received, and duplicate the complaints of many of my patients over the years.

Professor Driver Jowitt, I have found your info by accident and what I have read has confirmed some suspicions I have had about my own care for some time.

About 30 years ago I had a Takata type disc extrusion which led to laminectomy discectomy including a dural tear and weeks on my back in hospital. It was not enjoyable.

I have just had a fusion to help with awful foot and leg pain due to instability and bilateral foraminal stenosis.

I still have pain in both legs and feet and my low back feels no more stable than before. I have suspected for a long time that I have not been fully informed on my true condition-based simply on how bad I often feel- and I know that my GP is taking his lead from the latest ‘expert’ and my outpourings are largely dismissed.

After all I have been ‘fixed’ now… so what is the problem???

My insurer is taking an increasingly hard line lately on folks like me. I am about to be sent for assessment by an independent contractor to determine if I can return to my trade as a carpenter. I fully expect this to be found to be true and my exit (from benefits) put into motion. I have not worked full time since 2002 – in great pain and discomfort – and lost my latest (light)job when I agreed to the fusion. I feel let down by my health services.

Dear Patient, I have the greatest sympathy for you. Medical investigatory techniques (including the most recently developed “scans”) are relatively crude. Therefore a meticulously accurate diagnosis is often lacking. At times the view is taken that “nothing shows, therefore nothing is wrong”. This is an inferior conclusion, which I often have to counter in Court. My argument is that “absence of evidence is not evidence of absence”.

By the same token, such an absence of an anatomical diagnosis defeats accurate treatment design.

However empirically and over a lifetime of involvement in vertebral management [both surgical and (mostly) non-surgical] the least dangerous and most effective form of management is in water, as described in my website.

I imagine you are seeking responses to those who might deem you “fit to work” and so cut your grants. If I can help further, please let me know.

Dear Doctor Driver-Jowitt, I have read some of your articles on spine surgery and tried, elsewhere, to contact you.

I am doing some research on my own situation post discectomy/laminectomy for Takata type extrusion (20mm) in 1989 and L5/S1 fusion recently. I have significant ongoing issues. I am a 52 year old ex tradesman.

Can you tell me how I can establish the current status of my ligamentum flavum? After reading what you have written I think I may have instability and weakness due to its removal in 1989. But how on earth would I know??

Dear Patient, As a beginning, it is not likely to be productive to return to the past in terms of unpicking previous events. What counts is to get going on a process of improving what you have at present.

However, having said that, it might also be important to provide your source of social benefits with some reasons why you may never have been truly “cured” following the original disc prolapse.

At the date of your original surgery it was widespread practice to excise the ligamentum flavum, and to strip away the inter-spinous/supra-spinous ligaments, as well as to elevate (and so inadvertently de-nervate) the mutifidus muscles. The last mentioned is an often unrecognised cause of “instability” as well as “transfer pathology” to segments above and below the segment of primary pathology.

Therefore those who might take the stance “you have been correctly treated, nothing can be found by experts now, and therefore you are fit to work as a carpenter” might well be wrong. Add the impairments at the disc level to other (unrelated and often subliminal) changes of age, and you could well have good reasons not to be able to return to work as a carpenter. Indeed if you are expected to build and mount trusses, or work on scaffolds and ladders, you should be prevented from those activities.

Have your hips been checked? An arthritis, at times not appreciated, can often exacerbate vertebral problems.

Ageing and orthopaedics

 

 

Excess mass. Many of the degenerative changes of ageing are associated with excess body mass. It is a common perception that as one ages body-mass should increase. At times I am told by my affronted patients “I have always weighed this much, since I was a youth. How can you expect me to weigh less now?”

 

Get older, thinner. The reality is that an “ideal” body weight, which is probably acquired at the end of growth should, with ageing, decreased progressively. The reasons are that there is a loss of both the weight of bone and the mass of muscle. Therefore if the bodyweight remains the same it must be because there is more fat.

 

The lungs and stomach. The vertebral column shortens was ageing, and therefore the volumes in both the abdomen and thorax decrease . If the same amount of fat (or progressively more fat) is compressed into the abdomen then the diaphragm will be lifted and the space in the thorax compressed. This may be one of the reasons why reflux oesophagitis increases with ageing, as does the hiatus hernia. Add to that decreases in respiratory capacity, often in lungs which are functioning sub-optimally, and one has extremely good reasons for reducing mass. Oesophageal reflux can cause further deterioration in the lungs, coughing at night and so the cycle continues.

 

Weaker body more load. Therefore we have the unsatisfactory situation with weaker muscles and more frail bones being expected to carry a far larger body-mass, comprising a primarily of fat.

 

Metabolic effects. Excessive fat is not innocuous, as it has a huge influence on the hormonal balance of the individual, including the factors that go to create a diabetes, and creating excess female hormone.

 

Weaker structural tissues. Structural tissues, such as ligaments and tendons  lose their mechanical strength with ageing. This is partly because the blood supply to those structures diminishes and partly because the reparative processes following minor injury are slower.

 

Exercise plays many roles in musculoskeletal health (as it does in the health of the entire biology).

 

Hormonal benefits of exercise. There are general effects of exercise, which stimulate the production of natural anti-inflammatory medication substances, natural antidepressants and natural analgesics. For those with aches and pains, as well as the sense of depression that inevitably accompanies the degenerative processes of ageing, these are exceedingly important.

 

Strengthening benefits of exercise. In more specific terms exercise will retain, or perhaps increase muscular bulk and strength, which is so vital in protecting the joints. The calorie burn will be the most effective way of reversing the ratio of fat to muscle.There is nothing better than low impact exercise (such as cycling and swimming) to stave off arthritic degeneration in the knee

Osteoporosis. Exercise is the most specific counter to osteoporosis.

 

What type of exercise? In the ageing body by far the most effective form of exercise is swimming. However, if an exercise program is to succeed, and for that matter if any exercise patterns are to succeed, it must be firmly scheduled, so that the exercise is consistent. Three times a week is probably ideal, with a necessary day of “recuperation” between each session.

 

Particular care with swimming. Those who have problems with the joints, particularly with the vertebral column, but also the large joints of the body, need to exercise particular care in swimming. A painful back or a dowager’s hump, and many forms of scoliosis can make it exceedingly hazardous to enter the water unassisted. It is recommended that swimmers with these problems should always be accompanied whilst in the water, at least in the beginning.

 

Swimming and Gym coaching. It is also recommended that a swimming coach be employed initially. Many elderly people will regard this advice with scorn, saying “that is for children and toddlers. I know how to swim”.
However this is not an appropriate answer. Anyone who wants to brush up their foreign language or musical instrument playing needs help as an adult. Perhaps even more important is the fine tuning of swimming skills, which will allow the swimmer a more effortless period of exercise, and  consequently a longer period of exercise. Ideally the aim is to churn through the water without significant tension or stress for forty or more minutes during the session.

 

Cycling is a realistic form of exercise, with great benefits, particularly, to the knee. This is because it develops the quadriceps and other muscles which control (and so protect) the knee joint. The loads on the lower limb during cycling are less than walking and running, whilst the range of movement is often more than walking. If there are disabilities in the knees which prevent adequate movement then the use of shorter pedals shanks can overcome the problem. Ideally, adjustable shanks could be used and as the range of movement in the knee increases, so the length of the shank can be increased.

 

Cycling has the advantage that one can listen to music, dialogue or watch television. Reading a book is not realistic because of the jolting and sweating.

 

Making exercise fun. This is an important aspect of exercise as a therapy. Exercise must be attractive, appealing and fun. If exercise is a drudge then enthusiasm will be lost rapidly and ultimately the endeavour will fail, leaving only a large burden of guilt.

It is therefore suggested that careful attention be given to the “fun” aspects of exercise. The iPod has created a new dimension of music and literary content, and it might be that the iPod should be bought before the exercise bicycle.

Real cycling is an option which can give much additional interest to exercise, as well as a social and even the travel aspects. Many people combine an exercise bicycle with the “real” bicycle, and so are able to enjoy summer but continue to exercise during winter.

 

The importance of the logbook. Another ploy which is useful in maintaining stimulus and interest is to keep a detailed exercise logbook. This logbook should include details of the period of the exercise, and if it’s possible to measure  (as  is possible on many types of exercise bicycles) the total calorie burn. The logbook should also include a daily resting pulse (before getting out of bed) and the pulse rates before and after exercise as well as weight daily.
There is a tendency to forget how one improves was exercise and therefore the recording of this will not only stimulate the aim to keep improving, but demonstrate the efficacy of past exercise.

 

What can you expect if you  lose weight by reducing calories?

 

A number of chronic illnesses can be reversed, sometimes completely, simply by calorie reduced loss of weight. These include:

Diabetes of maturity

High blood pressure

Gout

Lower limb arthritis

Reflux oesophagitis

Respiratory incapacity and breathlessness

Prevention of hernias, or recurrence of hernias

 

Possible improvements include:

 A longer life. People (and animals) live longer on restricted calorie diets.

Reduced sleep disturbance from oesophagitis, reflux pharyngitis or apnoea

Urinary incontinence

Cardiac failure

Chronic bronchitis

Chronic sinusitis

Shoulder pain (when this is caused by lifting the body weight out of chairs).

Low back pain and sciatica.

Painful feet

 

All these illnesses are frequently treated by long-term medication. It seems so simple to be able to effect an improvement with less or no medication, at less cost, more energy, and a better quality of life by weight loss and exercise. Surely you owe it to yourself to try?

How does Chiropractic work?

Chiropractic was evolved as an empirical trade by DD Palmer in the late 1800s.  He was a teacher and grocer, who later became a “magnetic healer”.  Nine years later he conceived the idea of chiropractic.  His technique was based on the “adjustment” of bones. Palmer claimed that “a subluxed vertebra… is the cause of 95% of all diseases… the other 5% is caused by displaced joints other than those of the vertebral column“.

After a court case which ruled that chiropractic was a legitimate form of therapy it was marketed as a science and DD Palmer later claimed to be a philosopher.

DD Palmer started a school of chiropractic, perhaps not surprising with his teaching background, which allowed chiropractic to proliferate.  He repeatedly contended that he was not practicing medicine and had been imprisoned for practicing medicine without a licence.  His son took over the school of chiropractic and considered declaring chiropractic a religion (perhaps for the tax benefits available in the USA at that date).

The object of this post is not to give a critical overview of chiropractic.  Instead Paul Ingraham’s excellent commentary at http://saveyourself.ca is recommended.

What is unlikely to be disputed is that chiropractic is a large industry, and clearly there must be client satisfaction for it to survive commercially.

Where patient benefit results a “scientific” explanation might be of secondary importance. However an importance exists in that by an understanding the degree or frequency of benefit might be improved, or extrapolated to other illnesses.

Unfortunately chiropractors have proffered many explanations of their treatment which have little rational support. Often the “explanations” are no more than hollow jargonizing. It seems that a (perhaps the main) reason is to enhance their prestige and credibility as “science based” practitioners. Some claims (such as “correcting leg length inequality”) are fraudulent. Ironically it is this attempt at establishing “credibility” which does most to discredit chiropractic. The chiropractor could be well advised not to explain the reasons why their treatment is beneficial, and simply offer the service, letting it speak by results.

The foundation of chiropractic has been the management of vertebral pain by manipulative treatment, particularly rotary and hyperextension manipulation.  A “successful” manipulation, usually associated with satisfying clicks from the vertebral column, often dramatically lessens pain.

The question becomes “where does the pain come from and why does ‘clicking’ help? ”

In the 1970s I harvested a large number of cadaveric vertebrae. These vertebrae were stereo-radiographed, dissected, and after removal of soft tissue, using the stereo-radiograms, reassembled in the in vivo positions.

One purpose was to familiarize vertebral surgeons (myself included) with the large variation in the anatomy of the vertebral column.

In addition the facet joints anatomy and the mechanics of the facet joints in relation to orientation and instant locus of movement in to each other were explored. From that was extrapolated the relationship to the vectored loads on the intervertebral disc and the inter-segmental locus of movement.

In another study arthrograms were performed on a number of facet joints in these cadaveric spines with the soft tissues intact.  An example is below.

In the context of this paper, the most important finding of this research was the presence of an operculum in the facet joint capsule, which allowed passage through the capsule of a neurovascular bundle, into the intra-articular space.  Also demonstrated were features of the intra-articular fat within the capsule. [A later post will consider the function of the intra-articular fat.]

Much vertebral pain is clearly mechanical (because of its instant onset), and chiropractic (at least in its manipulative therapy guise) must provide a mechanical solution in order to cause the instant relief from pain. Therefore a mechanical sequence must be sought in any explanation of chiropractic benefit.

This paper postulates that the origin of some back pain (and the associated muscular spasm) is that the intra/extra-articular fat became entrapped in the operculum in the capsule.  This could explain the sudden onset of the pain. What the rotary manipulation does is to produce an intra-articular cavitation effect (and hence the click). Cavitation produces sudden changes of pressure within the joint capsule which forces the entrapped fat from its “locked” position in the operculum: Hence the instant relief.

Supporting this hypothesis was the beneficial treatment of “acute lumbar pain” by intra-articular injections of local anaesthetic and cortico steroid into the articular joints under radiological imaging, of which I performed many thousands, in the early 1970s.  The percentage of success was high, usually with an instant relief of pain comparable to that of successful chiropractic.  The long-term results appeared to be better than chiropractic.  A possible explanation for the latter is that the steroid produced an atrophy of the fat and hence less likelihood of future entrapment.  [Whether this atrophy caused some loss of proprioceptive capacity I don’t know, but it was one of my concerns at the time.]

A further benefit was the radiological demonstration of the vertebrae, a necessary precaution often not performed by the chiropractor. As a result of chiropractors missing these primary pathologies, and perhaps excessive forces, a number of patients were paralyzed or died when treated by chiropractic. This acted as a disincentive for some chiropractors who then replaced manipulative management with other techniques, such as “wedging”, or ventured into dietary supplements and other areas in order to continue their trade. Some claim or imply the special capacity to offer “holistic” treatment.

http://www.sciencebase.com/science-blog/how-does-chiropractic-work

 

What is meant by this, and the reason that superiority of chiropractic over other forms of healthcare in this respect is far from clear.

 

[Documentation that injury can follow chiropractic has been requested. Under the search term “Chiropractic causing paralysis” Google provided 155,000 entries.

http://www.medscape.com/viewarticle/726445_2

The papar http://www.ptjournal.org/cgi/content/full/79/1/50 is a comprehensive study.]