PHYSICAL MEDICINE SYNERGY

Conventional & Alternative Treatments for Back & Knee Pain: Two Case Reports
Pain is the primary reason people seek medical attention. The sources of pain vary from a cold & flu, an upset stomach, a headache, menstrual cramps, or muscle & joint pain. The most common source of pain is musculoskeletal in origin which is muscle and joint pain. Approximately 80% of Americans will suffer a musculoskeletal injury in their lifetime. Over 50% of Americans will lose 1-3 days of work due this pain. Over working in the garden, weekend warrior activities, carrying the backpack, lifting the children, repetitive activities, and even a lack of activity due to a sedentary lifestyle can cause havoc in your muscles and joints. If the pain doesn’t subside with the usual self treatment of rest over-the-counter medication, what do you do about it? Who do you see? Approximately 20 to 38% of American seek out chiropractic care. The remaining percentages stick to conventional medical care. Still others seek a mixture of medical, chiropractic, acupuncture, and/or massage therapies. The RAND Study in 1996 found that spinal manipulation was helpful for low back pain. Also, limited use of analgesics and exercise therapy are also very helpful. A combination of therapies offers a synergy that facilitates relief of pain and subsequent healing. A health care provider who can effectively provide chiropractic medicine (spinal manipulation & physiotherapy) and conventional medicine (medication & pain injections) as well as exercise therapy (stretching & strengthening) is a powerful and efficient weapon against musculoskeletal pain. Please indulge these examples as proof. Example 1: CW was a 39 years old male in very good shape, but threw his back out while playing golf. He presented to the office in an antalgic gait (he was bent over and walking slowly due to pain). His pain level was 9/10, with 10 being the worst. After performing a history and physical and an orthopedic assessment, it was determined that his pain was not neurologic, but rather musculoskeletal in origin. Massage was performed to help the muscles relax. Spinal manipulation was then performed to re-align hypomobile joints of his lower back. Trigger point injections were performed along the paraspinal muscles to ease the pain and spasm. Because he presented before a long holiday weekend and had to travel the next day, he was also given a shot of Toradol to

reduce pain & inflammation. Cold packs were placed on his back to reduce pain & inflammation. He was released with a prescription of muscle relaxers and analgesics. He returned the 4 days later, with his pain reduced to 5-6/10. Again, massage, and spinal manipulation were performed. Electric stimulation and heat was applied to his back. He returned 3 days later, with his pain now reduced to 2-3/10. Massage, spinal manipulation, heat and electrical stimulation were again applied. After another 2 days, he reported no more pain. His condition took only 3 visits to cure. A chiropractor can only perform manipulation and would have to treat him at least 9-12 visits. Further, he would still be considerable pain in the interim. A family doctor would prescribe the medication only once, perhaps 2 times, but his spinal dysfunctions (hypomobility) would have gone untreated. A pain management doctor could prescribe the medication and perform the injections to reduce pain and spasm. But this specialist typically needs a referral from the family doctor. In sum, this patient would have to otherwise visit 2-3 different doctors and pay a co-pay for each doctor, take more time to travel, fill out forms at each office, and miss more work. Our patient spent less, traveled less, and missed less work coming to our office in the first place. Example 2: KC was a 27 years old male who had log standing left knee pain as well as chronic spasms in the lower back. The left knee pain was aggravated by walking up or down stairs. He had a MRI of the left knee which found some minor ligament damage. Per the patient, two orthopedic surgeons said there was nothing they can do for him right now as he is too young for a total knee replacement and he does not have the insurance coverage for surgical repair of the ligament. His low back pain history was significant for a fall 6 years earlier when he was hit by a car. Occasionally, his back pain prevented a good night’s rest. Initially, his low back pain was rated 8 out of 10, that affected him 80% of the day. His left knee pain ranged from 5-9 out of 10, and bothered him 50-60% of the day. Treatment for the left knee consisted of an intra-articular joint injection or Prolotherapy injection, which uses natural medicines to help the ligament heal, become more stable, and thereby less painful. This was followed by joint mobilization to improve range of motion and ensure good movement of the injected medication.

Treatment of the lower back consisted of spinal manipulation and trigger point injections into the paraspinal muscles. A cocktail of conventional and natural medications were injected to decrease pain and facilitate healing. Afterwards, heat was applied to relax the muscles. Three days later the patient reported that his left knee pain had reduced to 2-3 out of 10 and was present only 10% of the day. He denied any more pain with walking up or down stairs as before. His back pain had also reduced to 3 out of 10 and was present only 5-10% of the day. He was able to sleep better and he denied any more left knee pain with walking up or down stairs as before. He had a significant recovery in only 1 visit. There were terms introduced that the reader should be familiar with if interested: trigger point injections, prolo (intra-articular) injections, and spinal manipulation. What are trigger points and trigger point injections? Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. They produce pain locally and in a referred pattern and often accompany chronic musculoskeletal disorders. Acute trauma or repetitive microtrauma may lead to the development of a trigger point. Lack of exercise, prolonged poor posture, vitamin deficiencies, sleep disturbances, and joint problems may all predispose to the development of microtrauma. Occupational or recreational activities that produce repetitive stress on a specific muscle or muscle group commonly cause chronic stress in muscle fibers, leading to trigger points. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation of pain. Trigger-point injection (TPI) has become widely accepted and is one of the most effective treatment options available to achieve the best results. Stretching exercises and physical therapy can also be helpful. Medications, such as anlgesics and muscle relaxers often help the patient sleep more restfully and diminish the pain. Chiropractic manipulation 1-3x/week and massage 1-2x/week are also very helpful in conjunction with the TPI. Typically, most patients will need up to 3 or more series of trigger point injections, 1 week apart. What is prolo (intra-articular) injections? Prolotherapy, aka Regenerative Injection Therapy (RIT), has been practiced for over 70 years. It is defined by Webster's New Collegiate Dictionary as, “The rehabilitation of an incompetent structure such as a ligament or tendon, by the induced proliferation of new

cells.” It was developed over fifty years ago as a natural non-surgical method of assisting the body in healing injured tendons and ligaments. Prolotherapy helps your body make new cells, which strengthen lax or torn tendons and ligaments. A needle is used to inject a proliferative, nutritive solution such as dextrose and glucosamine sulfate for the purpose of stimulating new growth and repair via fibroblasts (the body’s repair cells). Fibroblasts lay down new connective tissue. This promotes joint stability and reduction of pain. What is manipulation? Manipulation has been practiced since the day of Hippocrates (Father of Medicine, circa 460-377 BC). Almost every ancient culture (Chinese, Greeks, and Egyptians) had some form of manual medicine. Spinal manipulation was popularized in the United States in the late 1800’s by Dr. D. D. Palmer, DC, the Father of Chiropractic Medicine (DC), and by Dr. A.T. Still, MD, DO, the Father of Osteopathic Medicine (DO), as well as by Dr. Benedict Lust, MD, DO, ND, the Father of Naturopathic Medicine (ND or NMD). Today, while osteopaths (DO’s) are taught some manipulation, and many ND’s defer manipulation, most manipulation is still performed by chiropractors (DC’s). Spinal manipulation performed by DC’s, DO’s, and ND’s serves to decrease pain by the realignment of a dysfunctional joint, which restores normal tone in the muscle that attaches to the treated joint. The net result is decreased pain and spasm as well as regeneration of the joint. What is unique about the care at Solaris Medical is the manual medicine delivered by Dr. McWilliams can be coupled with conventional medicine. This integration of disciplines allows the patient, suffering from pain, to not only benefit from the relief and regenerative abilities that manipulation affords, but also achieve relief from medications and injections that are also known to provide pain relief. Whereas chiropractors (DC’s), can NOT prescribe medications nor inject, and whereas most medical doctors (MD’s & DO’s), can not or do not manipulate, a doctor who is medically trained, licensed, and experienced in conventional and natural medicines, can provide the structural relief of manipulation, the pain relief of medications and injections (trigger point and Prolotherapy), and the advice of rehabilitative exercise. For many, their health insurance may cover the trigger point injections, Prolotherapy, and manipulation. Dr. Kenneth McWilliams, has degrees in medicine (NMD), chiropractic (DC), and exercise physiology (MEd). Further, he is a Diplomate in the American Academy of Pain Management, and a past Fellow of the American Back Society. He may be contacted at SolarisDentistryandMedical.com or 480-802-6617.
Description: Back & knee pain is often treated by medical docotors and chiropractors, but each offer an advantage that the other does no have. The patient suffers, needlessly because of the lack of synergy between the various disciplines of health care delivery. An exceptional method of treatment is to combine conventional with alternative medicines under 1 roof.

Key words: physical medicine, manipulation, adjustment, chiropractic, conventional medicine, trigger point injections, Prolotherapy, back pain, knee pain, Solaris, rehabilitation