The Continuing Story on Back Pain and Genetics

Back pain and genetics, a continuing story...

Part I

The recent study on back pain and genetics:

Lumbar Disc Disease is Very Popular and Should Not Be Considered the Same as Back Pain

There is a recent exciting but currently unhelpful study on back pain and genetics.  The study was done by British researchers who pooled available data from several studies (a meta-analysis), that was recently published in Annals of Rheumatologic Disease.   It suggests that there is a gene that is associated with lumbar disc disease.  It may lead to future studies that are helpful.  What they did is look at DNA for 4600 individual for whom they also had imaging (x-rays, CAT scan or MRI).  They found there was a strong association for a few specific changes in one particular gene called "PARK2" and visible changes on the imaging.  This suggests that some change (likely considered a defect) in this gene is associated with changes on the imaging that suggested lumbar disc disease.  Lumbar disc disease is present in a large amount of the population, from 25% to 75%, depending on the study.  It's important to know that Lumbar disc disease is not the same thing as back pain.  You can have back pain without having any lumbar disc disease.  You can also have lumbar disc disease and have no back pain or other symptoms.  Lumbar disc disease is however, associated with the more severe types of back pain.  Lumbar disc disease is generally associated with sciatica, symptoms that travel from your lower back into one or both of your legs.  

The Question of Gene Therapy is Often Addressed While Discussing Possible Remedies to Lumber Disc Disease

As this information is better studied, there are questions that people will try to answer.

First question is; can we directly address back pain by doing something to give people the normal form of the protein or gene?  Most likely not. It is unclear exactly what the gene does in the body, and giving the body more of that protein does not mean that the body would incorporate the protein into the body in a useful way.  There is no way of knowing it would be safe.  An even more unclear group of techniques is gene therapy.   Gene therapy is a highly experimental field of medicine where a defect in a gene is addressed by actually introducing the normal form of the gene into the patient.   It has had a few successes, but most attempts have yielded more promise than results. 

What does PARK2 actually do?  Unfortunately for people who were hoping for a simple answer, probably a lot.  PARK2 is associated with a protein called ubiquitin.  Ubiquitin is called that because it's found in almost in all tissues in the body.  The proteins are involved in breaking down proteins in the body.  Proteins, at varying rates, are constantly made, then taken apart, then remade, and it's thought that PARK2 may be involved in regulating how this happens.  PARK2 is very unlikely to be a protein only involved in making your back healthy, it's also found in many tissues throughout the body.  Changing PARK 2 expression throughout the body could very likely have unseen results.  In the words of Buckaroo Banzai, famous world adventurer and neurosurgeon, "Don't tug on that.  You never know what it may be attached to."

One promising avenue for research is that will hopefully lead to studies that break back pain patients down into different groups.  As a clinician who has used a variety of different techniques, it is clear that not everyone responds well to the same approach.  Some patients benefit tremendously from chiropractic manipulation, others respond well to traction, other respond well to deep tissue or myofascial release while others respond well to exercise.  Some respond best to a combination of these approaches.  Very often, we don't know what will work best unless we've tried one or more of these techniques.  Knowing that there is a gene that is linked to different types of changes in the back may mean that there is a better way to treat a patient who has a certain form of the gene.  There may eventually be a blood test that suggests the best way to treat someone's back pain.

It may give us a better insight as to how disc degeneration occurs, and possibly suggest medications that directly affect this pathway.  If someone shows early signs of disc degeneration, there may be a new or even an existing medicine that affects the pathway and prevents it from getting worse.  

Currently surgery is used as a last resort for back pain patients. The reason being is that, even with modern minimally invasive surgery, there is still some risk, and not everyone is helped.  Some are even worse off after surgery.   It may be that certain forms of the gene are correlated with better or worse success, and would better allow surgeons to identify patients who they are most likely to help with surgery.  

Before I was a chiropractor, I worked in a biochemistry lab for eight years, looking at molecular biology of extracellular matrix proteins.  I have insight into how a gene may affect the entirety of an organism.   I'll be enlarging on genetics and back pain in future blog posts.  In the meanwhile, I will continue to apply evidence based techniques of chiropractic and physical therapy in my Rockville practice.  

For more information and health tips, visit the Rosa Chiropractic Rockville website and like us on Facebook.

 Dr. Charlie Ginsburg has a strong research background, having spent eight years in the field of connective tissue biochemistry. His practice focuses on the treatment of acute and chronic musculoskeletal injuries to the extremities and the spine. He uses physical therapy, rehab and chiropractic techniques, and incorporates ergonomics and therapeutic exercise into patients' treatment. He believes in inter-professional collaboration, and has strong relationships with members of the medical community and diverse alternative practitioners. Dr. Ginsburg has special interests in evidence-based medicine and martial arts injuries. He has a Bachelor of Arts from Vassar College, spent six years in the PhD program at Boston University School of Medicine (ABD), and has a Doctorate of Chiropractic from the National College of Chiropractic.  He is licensed in Maryland as a Chiropractor with Physical Therapy Privileges.

Rosa Chiropractic and Physical Therapy Center maintains an active presence on many popular search and social media websites. Select your favorite website below to stay connected or review us.

       

Lack of Exercise as a Medical Condition

A recent editorial in the Journal of Physiology asked the question whether deconditioning should be medicalized.  The author, Dr. Michael Joyner, a medical doctor and researcher at the Mayo Clinic, points out that 3 months of exercise training can reverse or improve the syndrome of postural orthostatic tachycardia syndrome (POTS). This syndrome is an excessive heart rate response to standing, a high heart rate response to a given level of exertion, and also involves reduced exercise capacity. While a number of pathophysiological explanations for POTS exist, over the last 5–10 years several labs have noted that the pathophysiology of POTS bears a striking resemblance to extreme forms of deconditioning such as prolonged bed rest.

 In thinking of this syndrome, the author considers whether not exercising should be considered a medical condition, in the same way that diabetes or obesity are a condition.  In reading his editorial, I appreciated that the author did emphasize the importance of a supportive environment and that exercise is often a preferable intervention over medication.  I think it's wonderful that this pathway is being considered more often in medical decision making.

I will add that it's sometimes inappropriately prescribed, in that I've seen patients  presenting with acute lower back pain who have been told the cause of their pain is their weight, and that they first need to lose some weight.  While treating obesity is a worthwhile goal, it's inherently unkind to tell someone this.  While exercise is usually good for back pain, the expectation that weight loss is a prerequisite to reducing pain has certainly not been established.  Very often, a patient with acute pain can not exercise efficiently, not to the extent of leading to any significant weight loss.  While moderate exercise that does not increase pain is a recognized evidence based intervention for back pain, expecting that exercising to the point of reversing obesity while also experiencing severe pain is setting the patient up for failure.  It's not news to the vast majority of patients that obesity is a bad thing.  Most patients are starkly aware of it, and some dread talking about because they feel that any pain they have is their fault for being lazy.  It takes no effort for a doctor to say "lose some weight", but it difficult to do under the best of circumstances, it can be much harder with untreated pain.  Bad pain happens to good people.  Skinny patients have severe back pain too, and shaming a patient in pain is simply kicking them when they're down.  While I'll almost always try to find some pain free exercising/stretching to help with a condition, I will also make sure the patient isn't trying to do too much to soon.  Doing too much invariably leads to the patient getting the feeback that exercise=pain, and overall discourages healthy exercise. As a chiropractor also trained in physical therapy, my strategy in my Rockville office is to offer several modalities at once, some which are passive that help relieve pain as soon as possible, while also suggesting the proper dosage of recommended exercises that can be done in a close to pain free manner.

On the other hand, I've also had patients in pain who've had their doctor take off their favorite form of exercise, with no game plan to return them to it.  My brother, a lifelong runner, told me once of the adage "Never go to a doctor who doesn't run, cause they'll just tell you to stop running".  This is still true, and I still commonly hear bed rest being prescribed for back pain, despite several studies finding that it typically exacerbates the condition.  Some patients have essentially had "exercise deprivation" inflicted on them by their doctor.  Given the plethora of benefits that research has found that  exercise can bring (alleviation of diabetes, obesity, hypertension; improved mood, better sex life, lower incidence of cancer, exercise and falls), its frankly dangerous to take away exercise without having a strategy for it's resumption.  I was inspired to enter my field at least partly due to multiple medical doctors telling me to give up my form of exercise (martial arts).  While this was an obvious solution, it was not a helpful one.  It was a chiropractor who said "Charlie, if I told you to stop doing karate and teaching self-defense, I'm guessing you'd ignore me anyway, so here's how we'll treat it".  He was the first to explain the involed anatomy, the likely diagnosis, and how to exercise as I wanted with no problems.  Seventeen years later, I'm still in the same martial arts style.  This sensible approach is what I've emulated in my practice, and I'm happiest on hearing back from patients that they're once more doing the form of exercise they love.  

If you've a question on how I can help, whether you're leery of cracking, feel that you need it or aren't sure, please call,   301-545-0800 or emailcginsburg@abcclinics.com.  

If I Come to See the Chiropractor, do I Need to get my Neck or Back Cracked?

Do I Need to Get my Back Cracked by a Chiropractor?

This is a common question that's often asked of me.  The short answer is "no".  The chiropractic school that I chose, the National College of Chiropractic, (now the "National University of Health Science"), excels in offering a wide variety of helpful techniques to relieve pain and problems.  Most involve no "cracking" or manipulation.  I should first state that manipulation is a safe technique with an excellent safety record.  It has been well studied with risks of serious complication being about 1 out of 5.85 million for an adjustment to the neck from a trained chiropractor.  These are much safer odds than the risks of routine usage of over the counter pain medications.  

I don't say this to discourage people from taking medication, medication can be a safe effective way of improving your quality of life, and I wouldn't wish to deny that to anyone.  I just wish to offer this information so that people realize chiropractic is a safe approach.  

Adjustments to the Back are Safer

Adjustments to the back or extremities (shoulders, hands, ankles or feet) are even safer then adjustments to the neck.

Since it's safe, why shouldn't everyone who needs it get manipulation?  Comfort.  Some people just don't like the idea of it.  It's usually that there is a fear of the noise and what it represents.  What is the noise? In your neck and back is a series of joints. One of the causes of pain is the joints not moving smoothly in relation to each other. When you receive an adjustment, you are getting a deep stretch of these joints.  

Joints are Capsules Sealing in Fluid Between Bones

In the joints there is a capsule sealing in fluid between the bones.  In the fluid, there are dissolved gases.  When the joint gets the needed stretch, the space between the joint stretches apart a tiny bit, so that the parts of the joint can reset itself and find a more natural position in which your neck and back can move more easily.  In that process, the volume of the joint is briefly increased, in that instant the volume increases, causing the gases to pop out of solution, similar to what happens when you uncork a bottle of champagne.  

The bones are not rubbing against each other, and tiny bones are not being cracked. Sometimes some people have had it done and decided they didn't like it.  Many who've been afraid of having it done have decided it actually felt really good. Besides comfort, there are some absolute medical contraindications, such as active cancer, fracture or clotting disorders, so it's not applied in those situations.

Everyone Should Get Adjusted!

I used to work with a doctor who felt that it was important that everyone get adjusted.  He would argue with and scold patients and do everything he could to get them to agree to an adjustment. He was my boss at the time and told me to do argue with any patients who didn't want to get adjusted.  But I found many people intellectually realized it was safe, but still didn't want to get it done.  I soon decided that the benefit didn't necessarily trump their discomfort. Also, I don't enjoy arguing as much as he did.  I told people that it was safe and effective, that it would often make their improvement occur faster, but that it was ultimately their decision and that I was comfortable with whatever they wanted to do.  But I told them that if the boss ever asked, tell him that I'd argued for long periods of time.  I felt then and feel now, that the time spent arguing was time that could have been much better spent doing something (not involving cracking) that still helped the patient.  I use many soft tissue techniques (myofascial release/brief massage/manual trigger point work/assisted stretching), specific exercises and stretches that are also quite effective, so there were still many ways to help patients.  In my current office, we also have state of the art Class IV laser therapy, computerized mechanical decompression traction for neck and back, as well as the old standby's of electrical stimulation and ultrasound, so I'm rarely without a way to helps someone.   

If you've a question on how I can help, whether you're leery of cracking, feel that you need it or aren't sure, please call!

For more information and health tips, visit the Rosa Chiropractic Rockville website and like us on Facebook.

 Dr. Charlie Ginsburg has a strong research background, having spent eight years in the field of connective tissue biochemistry. His practice focuses on the treatment of acute and chronic musculoskeletal injuries to the extremities and the spine. He uses physical therapy, rehab and chiropractic techniques, and incorporates ergonomics and therapeutic exercise into patients' treatment. He believes in inter-professional collaboration, and has strong relationships with members of the medical community and diverse alternative practitioners. Dr. Ginsburg has special interests in evidence-based medicine and martial arts injuries. He has a Bachelor of Arts from Vassar College, spent six years in the PhD program at Boston University School of Medicine (ABD), and has a Doctorate of Chiropractic from the National College of Chiropractic.  He is licensed in Maryland as a Chiropractor with Physical Therapy Privileges.

Rosa Chiropractic and Physical Therapy Center maintains an active presence on many popular search and social media websites. Select your favorite website below to stay connected or review us.