Performed at MWA by Michael Steinhauser, D.C. & Martin Gallagher, M.D., D.C.
BACK PAIN Economic, Epidemiology, Surgery, Treatment
Up to 80% of all adults will eventually experience back pain. This is a leading reason for physician office visits, hospitalization and surgery, and for work disability. The annual combined cost of back pain-related medical care and disability compensation may reach $50 billion in the U.S. The paradox is that, as the American economy is increasingly postindustrial, with less heavy labor, more automation and more robotics, and medicine has consistently improved diagnostic imaging of the spine and developed new forms of surgical and nonsurgical therapy, work disability caused by back pain has steadily risen.
Most back-pain patients will substantially and rapidly recover, even when their pain is severe. Only a minority of patients with back pain will miss work because of it. At any given time, about 1% of the work force is chronically disabled because of back problems. Recurrences of back pain are common, and the majority of patients will experience them. Up to 85% of patients with low-back pain do not receive a definitive diagnosis. X-rays are not only costly but can increase the risk of radiation exposure and do not clarify the reasons for pain.
Computed Tomography (CT) scanning and magnetic resonance imaging (MRI) allow for the discovery of more precise diagnoses, but there is an alarming rate of abnormalities in pain-free individuals. MRI has found herniated disks in approximately one-fifth of pain-free subjects under age 60.
In one particular study, spinal stenosis, which is rare in young adults, occurred in about one-fifth of those over the age of 60 who were pain-free. Surgery rates for back pain vary from country to country. The U.S. has 5 times as many back operations performed as England. One to 2 weeks of strict bed rest for back pain was the norm until about 10 years ago. A variety of studies have shown that 2 days of bed rest were comparable to 7 days- worth of bed rest, as far as recovery. In another study, 4 days of bed rest turned out to be no more effective than 2 days. Studies have shown that people who remained active despite acute pain experienced less future chronic pain and used fewer health care services than patients who rested and waited for the pain to diminish. Though some people cannot go back to their physically demanding jobs, it is important for them to go back to light duty until they become fully capable.
Transcutaneous electrical nerve stimulation (TENS), traction and injection of the facet joints with cortisone-like drugs have not been proven to have any long-term benefit. There is growing evidence that exercise plays an important part in the prevention and treatment of back problems. Those who developed back pain and who regularly took part in structured exercises showed less recurrences and reduced work absences. Those experiencing chronic pain also benefitted from exercise.
Chiropractic is the most common alternative choice for back pain. Evidence accumulates that spinal manipulation may indeed be effective in short-term pain relief, but other alternative treatments or chiropractic have not shown any definitive answers with regard to long-term pain relief.
Most experts agree that disk surgery is only appropriate when there is a combination of a definite disk hernia on an imaging test, a corresponding pain syndrome, signs of nerve root irritation and failure to respond to 6 weeks of nonsurgical treatment. Herniated disks are most common in adults between 30 and 50 years of age. Recent studies show that herniated disks spontaneously recover as a rule. Because most back pain is not caused by herniated disks, the actual proportion of back-pain patients who are surgical candidates is only about 2%. Herniated disks still remain the most common reason for back surgery. Even though patients with back surgery had faster pain relief than did patients treated conservatively, the differences evaporated over time. At 4- and 10-year follow-ups, the 2 groups of patients were virtually indistinguishable. Surgeries for herniated disks increased 39% between 1979 and 1990. Stenosis surgeries increased 343%. Spinal stenosis is the most common reason for back surgery in those over the age of 65. The indications for surgery in spinal stenosis are less clear-cut than they are for herniated disks. Stenosis surgery is more complex than herniated disk surgery.
In conclusion, an approach to back pain may be to take pain relievers as needed, stay in good overall physical condition, keep active through an acute attack if at all possible and monitor the condition for changes over a few days or a week. It is noted that low-back pain is the fifth primary reason for adult visits to office-based physicians, after hypertension, pregnancy care, well care check-ups and upper respiratory infections, and followed by depression and anxiety, and diabetes.
"Low-Back Pain," Deyo, RA, Scientific American, August, 1998;279(2):48-53.
Shed Pounds with Mindful Eating? New review finds encouraging evidence for the power of conscious dining 06/28/2018 By Michelle Lee with Craig Weatherby
How much do you think about eating?For most of us, eating is a mindless activity, something we do to satisfy hunger. If weight loss or weight control is a priority, you may want to rethink your approach.
What exactly is “mindful” eating?
It means paying attention to our thoughts, desires, and stomachs. A new review of the published evidence found that mindful eating — taking a more “conscious” approach to meals — can enhance efforts at weight loss.
Just as importantly, mindfulness means awareness without judgement. You’ll find 12 practical tips for mindful eating at the end of this article.
Before we get to the new evidence review, let’s examine a recent trial that examined the effects of an online mindful eating program.After we examine that review, we'll summarize a recent study on the effects of "slow eating", which plays a role in mindful eating, and brings its own benefits.North Carolina trial sees mindfulness aiding weight loss and controlThis controlled clinical trial examined the effectiveness of a program called Eat Smart, Move More, Weigh Less (ESMMWL) in achieving two goals:
The trial, led by Carolyn Dunn, Ph.D., of North Carolina State University, co-developer of the ESMMWL program, found that mindful eating can enhance weight loss efforts.
The ESMMWL program consists of a 15-week series of online classes — plus one-on-one remote counseling — designed to help participants become more mindful when eating.
The study involved 80 adults who used the ESMMWL online program for 15 weeks. Those who completed the 15-week program lost more weight than people assigned to the control group.
As the authors wrote, “[The study’s] results suggest that there is a beneficial association between mindful eating and weight loss." (Dunn C et al. 2017)And they stressed the novel nature of their study: “The current study contributes to the mindfulness literature as there are very few studies that employed rigorous methodology to examine the effectiveness of an intervention on mindful eating.”We should note that the study was conducted by the founders and operators of the Eat Smart, Move More, Weight Less program, so there may be some bias involved.
And we neither endorse nor have any connection to the program, but you can learn more on the ESMMWL website.People can either enroll for the online classes (which cost $235 as of this writing) as individuals, and employers can obtain group pricing.
Evidence review affirms the effectiveness of mindful eatingNutrition scientist Carolyn Dunn, PhD — who led the North Carolina State University study described above — also led the first-ever review of the clinical evidence on weight loss and mindful eating.
Encouragingly, their results show that every relevant clinical trial linked mindful eating to better success at weight control, while most (80%) of the studies found that mindful eaters continued to lose weight (Dunn C et al. 2018).
Why did mindful eating prove to be an effective approach to weight control?As Dr. Dunn’s team wrote, “Increased mindful eating has been shown to help participants gain awareness of their bodies, be more in tune to hunger and satiety, recognize external cues to eat, gain self-compassion, decrease food cravings, decrease problematic eating, and decrease reward-driven eating.”
The results of her team’s evidence review appear to be supported by two other recent evidence reviews (Ruffault A et al. 2016; Lyzwinski LN et al. 2018).
We should note that not every trial testing the effects of mindful eating found that it produced weight loss.
For example, a recent clinical trial from the University of California — which involved 194 adult volunteers and lasted almost six months — didn’t find that adding mindful eating to a diet-exercise program produced no additional weight loss.
However, people randomized to the mindful eating group did enjoy metabolic benefits that could aid weight control over long-term.As the California team wrote, “Mindfulness enhancements to a diet-exercise program did not show substantial weight loss benefit but may promote long-term improvement in some aspects of metabolic health in obesity that requires further study.” (Daubenmier J et al. 2016)
Key mindful eating tacticsCarolyn Dunn, Ph.D. — lead author of the 2018 literature review — offers 12 mindful eating strategies:
What about eating slower?Mindful eating isn’t the only approach to weight control that doesn’t require calorie-counting or favoring certain kinds of foods (such as protein and/or or fats versus carbs).
There’s good evidence that eating more slowly — along with eliminating after-dinner snacks and snacks within two hours of sleep — can assist with weight loss or control (see Slow Eating May Prevent Weight Gain).
Earlier this year, a British-Japanese team published the revealing results of their analysis of health data collected from 59,717 diabetic Japanese citizens who underwent regular check-ups between 2008 and 2013 (Hurst Y, Fukuda H 2018).
The international researchers had access to the BMI (body mass index), waist measurement, and blood test results from every participant’s checkup — as well as their answers to lifestyle questions, including sleep, eating, tobacco, and alcohol habits.
Importantly, the participants had been asked how quickly they typically ate, which allowed the researchers to categorize them as fast, slow, or normal-pace eaters: 22,070 reported eating quickly, 33,455 ate at a “normal” speed, and only 4,192 reported eating slowly.The participants also revealed how often they ate dinner within two hours of bedtime, how often they snacked after dinner, and how often they skipped breakfast.
Compared with the other two eating-speed categories, the slow eaters included a significantly higher proportion of women and lower proportion of obese individuals. The slow-eating group also had a lower average BMI, smaller average waist circumference, drank less alcohol, and smoked less tobacco.
In contrast, the fast-eating group included a significantly lower proportion of women but a significantly higher average BMI, higher proportion of obese people, and larger average waist circumference.
After accounting for factors that could affect BMI and waist circumference, the British-Japanese team’s analysis revealed that, compared to the “speed eaters,” those who ate at a normal speed were 29% less likely to be obese, while the slow eaters were 42% less likely to be obese.
Critically, when participants made changes in the speed at which they ate, this change in habit was associated with weight loss, lower levels of obesity and a smaller waist.This finding strongly suggests that speed of eating affects body weight, rather than healthier body weight indicating a naturally slower eating rate.
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