Chiropractors/disc injury/facet/SI

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QUESTION: Hi. Thanks for taking time to answer a couple of questions. 5 years ago I suffered a grade 5 lateral tear to disc L4. To this day I am still feeling pain. Pain doctor has diagnosed and treated bilateral lumbar facets with injections and Rhizotomy. SI joint been addressed which creates a lot of pain! My last MRI 2 years ago showed no impingement on nerves yet I am in constant pain.  A surgeon indicated treatment would be a fusion but I disagreed and he said I am too young (im 43).  This injury happened from shoveling snow in Nov of 2007. I did see a chiropractor who performed decompression traction on the disc which helped the disc.  Since then I am at a plateau- pain not getting any better and at times worse. Any advice?

ANSWER: Hi Michelle,

Sorry you've had such difficulty.    The first thing I'd want to know is whether you have a positive "Prone Instability Test."   You can see the PIT on line.   Here's an example: http://www.youtube.com/watch?v=86Xp_wTvuS0      If you have a +PIT, then you must be avoiding all lumbar spine motion exercises, the biggest bad one is an ab' crunch or sit up.    You'd have to focus on "spine neutral" core exercises.   Most trainers and all sports chiro's know what this is.    Assuming you've been avoiding lumbar spine flexion postures and keeping your lumbar spine neutral with your exercises and daily activities, and this, along with your other procedures has not worked, then we have to consider that the tear in your disc is causing your problem.    Disc tears can be a constant source of pain.   Discs don't heal well, and loading them up with the weight of your torso just squashed the disc and tugs away at the tear.    With a +PIT and disc tear, for some people, the only relief they get is with a surgical fusion.    But for some others, if they have not been doing neutral spine activities, whether it be exercises, or routine tasks such as lifting or sitting (see "the golfer's lift"), it's worth a shot trying it for a few weeks before making a surgical decision.   I'm curious if you had an epidural steriod injection (preferably an interlaminar ESI) to target the disc tear?   

'Hope this was helpful.

Dr. G'

---------- FOLLOW-UP ----------

QUESTION: Dr G- Yes I had a +pit.  Chiro was able to relieve the pain with the pressure.  I went to him for 4 years. The exercises were core strengthening crunches and they hurt. Especially on my facets. Question- should any exercises include weights?! With what ive read and my body has told me weight bearing exercises are not the best. My central balance is off and when i try the "bird dog " with my left arm and right leg extended i fall. Is that sign the disc is still torn?  
Im waiting for my records from the pain doc to see what he has actually done.  I do believe ive had some type of epidural.  
Neutral exercises... such as? The surgeon i did see had me get a back brace. It helps yet then i get feedback from a doc that "the brace is going to make your muscles weaker. Mri already shows atrophy with the muscles above facets going towards my spine. So i do not know who to listen to. The brace does make my back feel better.
Thanks! Michele

Answer
HI Michelle.   That was good information.  [by the way, see my "how to shovel snow" video on my web site in the "info/how to" tab]  The wrap-around back support will make you feel better.   It will take away some of the pain.  It is not a substitute for core strengthening.   I've never seen any evidence that is weakens the muscles, but everyone makes that conjecture.   I'll bet your doc' cannot find a piece of research that proves it.   That's just what some people suppose, but we don't know.   We do know that wearing a support will not prevent back injuries in the work place (thus Home Depot employees are no longer required to wear them).   We do know that muscle atrophy is seen in chronic back pain patients, and whether the pain causes the atrophy or if the atrophy leads to pain, or both, is still debated.    Depending on how unstable your lumbar spine is, some exercises will cause you more pain.    Standing squats with a 100 lb bar across your shoulders likely will cause trouble.      Do you have scoliosis?  Did the MRI mention "Modic" signs?   Scoliosis might be one explanation for why you have a weak side doing birddog on ball.   We often see this, and I'd say that in my years of experience watching people do birddog on ball, and me doing it myself, it is often we see the easier side and tougher side.   My ballroom dance instructor calls it the smart side and the dumb side, when struggling with moves that are easy going to the right but hard going to the left even though it's the same move.   "Modic signs" are when there is a combination of disc degeneration, thickening or sclerosis of the vertebral bone that connects to the disc, and edema of the adjacent bone marrow.   This is a generator of pain (you can google Modic-1 signs...).   Regarding birddog, Michelle, you might just have to focus on the weaker side (left arm/right leg), trying one set of fast reps, a set of slow reps, reps where you hold your position 1/3rd and 2/3rd's up through the rep, and holding an endurance rep for as long as you can.    As for other exercises, the simple side plank is a good one.   This is done in an endurance rep, not back/forth repetitive reps because that bends your spine into and out of neutral repetitively.   You can see this on my web site on the exercise tab.   Recent research demonstrated that in a side plank, abdominal oblique muscles engage, and also the deep paraspinal muscles engage.   For some people, the more they do side planks, the better their back feels.   The only problem with a side plank, especially in a full plank, is that it puts a lot of force on the shoulder.    The best way to do the plank is on a BOSU (that half ball).    If you place the BOSU dome up, lay sideways on it.   The side of your hip/pelvis will be on the apex of the dome, your elbow will be on the ground and arm/hand flat to the ground, and your legs/feet will be together  with the side of your foot against the floor.   Your up-side hand will be wrapped around your waist, with fingers feeling your abs, and thumb feeling your lower back muscles.    Then you lift your legs off the floor such that your body is straight.   You'll feel your back and ab's engage.   There will be no pressure on the shoulder.   You can turn your head and look down at your feet, making sure your feet stay together and that your torso remains sideways.   When you get good at this, you can play with engaging your ab's more or your lower back muscles more.   Do one endurance rep per side and repeat for two reps.   Do this at least 3x/week.   A strong back will be able to hold this position on a BOSU for at least a minute if not more.   If you are positioned too high up on the ball, hip ahead of the apex, it will be too easy.   If you are positioned too far down on the apex of the BOSU, it will be more difficult.   Find the balance point by playing with this.   Again, don't do repetitive bending of your lumbar spine (if you bend a wire hanger back and forth it will eventually break...so do your discs, thus no ab' crunches, for example).    

Let me know if all this was helpful.   

Dr. G'

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Scott F. Gillman, DC, DACBSP

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21 Years in practice: I can answer any question regarding chiropractic and sports medicine treatment. Mostly, I can help the unknowing public understand what is safe, valid, reasonable and evidence-based, and what kinds of unscrupulous chiropractors and fraudulent methods to stay away from. I have an advanced specialty degree in Chiropractic Sports Medicine. I have experience treating elite and Olympic athletes.

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