Making Sense of Guidelines for Care

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Not too long ago, the Eighth Joint National Committee (originally commissioned by the National Heart, Lung, and Blood Institute) released a new set of evidence-based guidelines for evaluation and treatment of hypertension (high blood pressure). The guidelines committee, comprised of 17 academics, spent five years reviewing evidence as preparation for developing the new recommendations.

The committee’s report represents nothing less than a sea change in the treatment of patients with higher-than-normal blood pressure readings. The primary shift is from a long-held standard of implementing treatment when a person’s blood pressure is higher than 140/90 mmHg. The new guidelines recommend beginning treatment only when blood pressure readings are higher than 150/90 mmHg. The new standard is a huge modification of decades-old practice methods, and has generated substantial controversy.^1.2 Of course, a good portion of the pushback is from those who have a vested interest in maintaining the status quo, such as physicians who dispense medications from their office and earn substantial income from selling antihypertensive drugs at multiples of their wholesale costs. In addition to physicians who act as pharmacies, drug companies who manufacture antihypertensive medications also stand to lose significant revenue. But aside from considerations related to the practice of medicine as a business, the real issues should be focused on the benefits and harms to patients. In this context, it may be reasonably stated that fewer medications are, by and large, a good thing.

The new blood pressure guidelines have two primary impacts. First, for people over age 60, treatment for presumed hypertension should be initiated when blood pressure readings are higher than 150/90 mm/Hg. More than 7.4 million Americans over age 60 will be in the new safe range. Many of these millions of people have been taking antihypertensive medication for years, possibly needlessly as implied by the new guidelines. Next, for all those under age 60, there is insufficient medical evidence that a systolic blood pressure (the first number in the reading) threshold exists that would dictate treatment. In other words, for many years the systolic threshold had been 140 (as in 140/90 mmHg). Higher systolic readings virtually mandated antihypertensive treatment. Although the committee expressed its opinion that the systolic threshold of 140 mmHg ought to be maintained for those younger than age 60, even though evidence for such a threshold is weak. Thus, it may be that many millions more people have been taking antihypertensive medication without such recommendations being backed by sound scientific research.

The point here is not that people should stop taking their blood pressure medication.³ All such types of decisions should be made in consultation with the prescribing physician. The main consideration is having the ability to make informed choices. Some medication regimens may be appropriate. Some may not. Some may need to be reevaluated. As always, regular chiropractic care is of value by providing you with the best opportunity to achieve maximum good health.

¹Mitka M:Groups spar over new hypertension guidelines. JAMA 311(7):663-664, 2014
²Kieldsen SE, et al: Hypertension management by practice guidelines. Blood Press 23(1):1-2, 2014
³Sheppard JP, et al: Missed opportunities in prevention of cardiovascular disease in primary care: a cross-sectional study. Br J Pract 2014, Jan;64(618):e38-46.

The Best Treatment for Trigger Points

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Trigger points are painful nodules in muscular tissue, commonly found in the upper back, low back, and gluteal muscles. Trigger points are frequently chronic, persisting from day to day without much relief. When someone says, “My muscles are all in knots”, those knots are most likely trigger points.

The formal definition of a trigger point describes a localized region of tenderness, located in a tight band of muscle, which is associated with a palpable twitch in response to deep pressure over the tight band.¹ Such deep pressure usually results in pain radiating from the trigger point to the surrounding soft tissues. Formally, if the twitch response is not present, the localized muscle tightness cannot accurately be termed a trigger point. It may also be argued that characterizing a local muscle “knot” as a trigger point requires the presence of the above mentioned radiating pain. These definitions are of importance when making decisions about appropriate care for painful muscle knots.

As with any care management decision-making process, some procedures make sense and others do not. Many so-called pain management physicians will recommend injecting painful trigger points with an anesthetic or even botulinum toxin.^2,3 Such an invasive procedure is rarely required. Pain management practitioners and even specialists in internal medicine will recommend muscle relaxers such as Robaxin, Flexeril, or even Soma in attempts to diminish muscular pain in the shoulders or low back that may or may not be associated with the presence of trigger points. The problem with such medications is they do not address the underlying cause of the painful muscle knots. Further, their efficacy with respect to muscular pain is questionable.

The mistake, as is frequently the case, is in thinking of trigger points as a real entity. But trigger points do not exist in a vacuum. These painful muscle knots arise as a consequence of mechanical disturbances and stress in the rest of the body. Attempting to treat the trigger points themselves with injections or medications misses the real problem. Trigger points have arisen in a person’s shoulders or low back owing to chronic issues elsewhere, typically involving the spinal column itself and the small muscles that enable those vertebras to move in three-dimensional space.

Trigger points are best managed by directing care to the underlying issues, primarily involving loss of full mobility of spinal vertebras and resultant inflammation in spinal muscles. As with many other biomechanical problems, chiropractic care is often the best solution. By utilizing a specific, highly targeted, noninvasive approach, chiropractic care helps alleviate the factors that have led to the painful muscle spasms known as trigger points. As the underlying biomechanics improve, the trigger points themselves begin to resolve, all without the need for injections or medications.

¹Fernández-de-las-Peñas C, Dommerholt J: Myofascial trigger points: peripheral or central phenomenon? Curr Rheumatol Rep 16(1):395, 2014
²Kim SA, et al: Ischemic compression after trigger point injection affect the treatment of myofascial trigger points. Ann Rehabil Med 37(4):541-546, 2013
³Zhou JY, Wang D: An update on botulinum toxin a injections of trigger points for myofascial pain. Curr Pain Headache Rep 18(1):386, 2014

Office Chair Advice

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For most people, it is quite a challenge to maintain good posture while sitting in an office chair and working for long hours in front of a computer. In fact, a surprising number of people sit at the front of their office chair and hunch forward in attempt to get closer to their computer screen. The computer is a very potent 'consciousness absorbing' device - it takes the mind away from the body and keeps it focused on what's on the screen instead.
This article reviews a simple, practical way to counteract this tendency to hunch forward and instead improve posture by keeping the body anchored to the back of the office chair.

Upright Posture

Both the abdominal muscles in the front of the spine and the back muscles in the back of the spine work to hold the body erect, like two elastic band positioned on either side of the spine. Forward leaning posture - hunching forward while sitting in an office chair - distorts this balancing system and places considerable strain on the back.
To illustrate the amount of strain on the back, think of the example of balancing a stationary motorcycle upright so that it doesn't tip over. If the motorcycle is properly balanced it can be held upright easily with one hand. Similarly, when one sits upright in an office chair, the abdominal and back muscles work in unison to maintain an erect posture with only minimal effort.
However, if the motorcycle leans over a bit there is a significant difference in the amount of effort it takes to keep the bike from falling over to the ground. The more the motorcycle leans, the more effort is needed to keep it from falling over. Similarly, when people hunch forward while sitting on an office chair their back muscles have to work much harder to hold the body up and keep it from falling forward.
Simply put, leaning forward 30 degrees in an attempt to get closer to the computer screen puts 3 to 4 times more strain on the back, causing advanced wear and tear on the joint surfaces, the ligaments of the spine, and the discs located between the vertebrae. The back muscles are also negatively affected as the continuous added strain causes them to tighten up, reducing optimal blood and nutrient flow to the back muscles. Over time this posture leads to the development of tight, rigid muscles and joints, which makes them more prone to injury.
One of the biggest misconceptions with sitting is that it doesn't require any muscular effort. This is absolutely false. The back muscles are continuously working to maintain the body in an upright posture while sitting. And for those who sit in an office chair and work for longs periods of time at a computer in a hunched forward posture, the structures in the back suffer considerable pain.

Technique to Avoid Hunching While Sitting in an Office Chair

To avoid the natural tendency to hunch forward while sitting in an office chair and working at a computer, this simple technique is fool-proof. Place a tennis ball between the middle back and the office chair on each side of the spine. Holding the tennis ball (or similar ball) in place while sitting and working at a computer accomplishes three things:

• Because the mind senses the ball, it remains with the body instead of being completely absorbed by what is on the computer screen. Maintaining more awareness of the body allows one to more easily maintain better posture.
• By leaning back into the tennis ball an acupressure effect is created, which stimulates blood flow into the area and physically releases contracted muscle and connective tissue. The pressure of the ball also creates a central nervous system mediated analgesic effect that is somewhat similar to acupuncture, loosening tight areas while sitting in the office chair and getting work done.
• Importantly, if one does get absorbed into work and starts to lean forward the tennis ball will fall out, serving as a concrete reminder to stop hunching forward and straining the back.

Please note that the above technique and the advice provided cost next to nothing, have no adverse side effects, and are quite easy to do. 

Healthy Backs and Regular Chiropractic Care

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Regular chiropractic care helps your body function at peak capacity. Your body is a dynamic structure and, as in all finely crafted machines, it's possible for subtle things to go wrong. The problem, of course, is that as these problems are subtle we don't know about them until, in a sense, it's too late. Too late, that is, from the point of view of how long it may take to get better now that the problem's been going on for some time.

By receiving regular chiropractic care you're helping to nip various physical problems in the bud. For example, low back stiffness, which if left unattended might develop into a mechanical problem and ultimately a herniated lumbar disc, is identified at the outset and lessened or resolved by regular chiropractic care. By helping you improve your overall health and well-being, regular chiropractic care is a modern implementation of the old proverb, "an ounce of prevention is worth a pound of cure".

Effective Diagnosis and Treatment of Low Back Pain

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Here's an all-too-common situation. You develop low back pain that lasts for more than a few days and you're uncomfortable enough to go see your primary care physician. He or she tells you it's not clear what's going on and sends you for a magnetic resonance imaging (MRI) study of your lumbar spine. The study comes back showing one or two herniated intervertebral discs. [Intervertebral discs are cartilaginous shock absorbers interspaced between pairs of spinal vertebras.] Your doctor informs you that you have "herniated discs in your back" and prescribes medications and a course of physical therapy. Your doctor may even refer you to an orthopedic surgeon to evaluate the need for surgery on your back.

Now, all of these recommendations may be necessary. Or none of them may be necessary and all that's needed is some rest and an exercise rehabilitation program that you could do on your own if you were given the proper instructions. The culprit here is how the presence of the herniated disc or discs is interpreted. It's important to remember that not all herniated discs are a problem requiring a solution. In fact, a sizable proportion of such disc herniations (30% or more)¹ represent the progression of natural processes and are not a problem at all.^2,3 But many family doctors and even specialists are not appropriately trained in accurate differentiation among the various possibilities. When faced with MRI evidence of a herniated disc, such doctors see it as a disorder or disease that needs to be treated and fixed. Such an approach results in significant stress and leads to unnecessary procedures and financial hardship for many patients.

Given the frequency of occurrence of such instances of "over-diagnosis", how can a person with back pain expect to receive appropriate care? Of course, people as patients are usually not in a position to be able to overrule their doctor's recommendations. The answer lies in obtaining relevant information. Let your doctor know you're aware that up to one-third of normal persons have herniated discs, and ask whether it's possible that your disc herniation is in fact unrelated to your back pain and merely an incidental finding. Further, if your back pain is not accompanied by leg pain radiating below your knee, it may be that the disc herniation is not affecting spinal nerve roots and may be treated by very conservative measures such as rest followed-up with exercise.

Thus, not all disc herniations have the same impact on a person's health. Some represent normal findings, even if they are present in a person who has back pain. Let your doctor explain to you exactly why your particular problem requires more than watchful waiting. Your local chiropractor will be able to provide you with the very best expert advice and recommendations for any necessary treatment.

¹Takatalo J, et al: Does lumbar disc degeneration on magnetic resonance imaging associate with low back symptom severity in young Finnish adults? Spine (Phila PA 1976) 36(25):2180-2189, 2011
²Spontaneous regression of herniated lumbar discs. Kim ES, et al: J Clin Neurosci 2013 Oct 24. pii: S0967-5868(13)00552-3. doi: 10.1016/j.jocn.2013.10.008. [Epub ahead of print]
³Endean A, et al: Potential of magnetic resonance imaging findings to refine case definition for mechanical low back pain in epidemiological studies: a systematic review. Spine (Phila PA 1976) 36(2):160-169, 2011