As medical providers we swear to "do no harm." So when considering the whole patient and taking into consideration the cost, overmedication, and medical harm associated with the management of low back pain, it is important for clinicians to consider the power of their diagnostic labelling words.

The study above provides evidence that the use of certain words such as "arthritis", "degeneration", and "disc bulge" when treating a patient with low back pain results in poorer patient perceptions about their condition. A patient who hears these words will likely have a lower expectation of their recovery, a higher chance of surgery and a greater perceived seriousness of their pain. Words like "lumbar sprain", "non-specific low back pain", and even simply "episode of back pain" have better patient beliefs and outcomes related to their low back pain, shifting their perspective and enabling them to feel more comfortable with accepting a non-invasive low risk medical treatment option like chiropractic rehab. Clinical guidelines recommend giving advice and reassurance to help reduce or avoid unnecessary tests and treatments for non-specific low back pain.

Consistent recommendations include:

• educating people about the nature of low back pain,
  
• reassurance that it is not a serious disease and will improve,
  
• encouragement to avoid bed rest,
  
• stay active, and
  
• return to usual activities.
  

The study found that providing reassurance does not remove the negative effects of the labels arthritis, degeneration and disc bulge. Overall, this study suggests that clinicians might consider avoiding labels like arthritis, degeneration and disc bulge. Instead, clinicians could consider using labels like an episode of back pain, lumbar sprain or non-specific LBP when communicating with patients with low back pain.

In chiropractic school we were trained ad nauseam to use incredibly specific diagnoses such as "Acute traumatic facet syndrome with associated myospasm, deep referred right leg pain and lumbar intersegmental joint dysfunction complicated by chronic degenerative hypertrophic osteoarthritis and Grade I L5/S1 spondylolisthesis." I have been a practicing physician for a while now and I whole-heartedly agree with this study. I have learned that my words greatly matter to what a patient thinks and how they believe they will progress over the course of care for their low back pain. While a working diagnosis like the one above may be beneficial knowledge to the treating clinician and could certainly impact the prognosis, it means nothing to a patient. Explaining in full medical detail to a patient what every bit of the diagnosis means to a patient could be detrimental to the success of treatment, leaving them feeling hopeless and that surgery may be inevitable.

As clinicians we must be better for our patients. They deserve it!  

Inflammation can have both positive and negative health effects. Acute inflammation works with the immune system to address infectious and non-infectious cellular damage. (1) However, when inflammation becomes chronic, it can seriously impact health. For example, studies have shown a correlation between chronic inflammation and all-cause, cancer, cardiovascular, and cerebrovascular mortality. (10)(12)

​You can find the following recommended supplements at https://us.fullscript.com/welcome/spokane-wellness

Curcumin
Curcumin (Curcuma longa)600–1,000 mg, total per day, minimum 8–10 weeks (4)(13)

• Curcumin decreased C-reactive protein (CRP) (-0.58 mg/l), tumor necrosis factor-alpha (TNF-α) (-3.48 pg/ml), interleukin 6 (IL-6) (-1.31 pg/ml), and malondialdehyde (MDA) (-0.33 umol/l), and increased superoxide dismutase (SOD) activity (20.51 u/l) and total antioxidant capacity (TAC) (0.21 mmol/l). (3)
• In patients with various chronic diseases, curcumin decreased CRP (-3.67 mg/l) and hs-CRP concentrations. (4) 
• Compared to placebo, curcumin decreased IL-6 by ~49%, TNF-α by ~63%, and MDA by ~38% in patients with diabetes mellitus. (13)

Omega-3 fatty acids (EPA/DHA)
Omega-3 fatty acids (EPA/DHA)2.5 g, total per day, minimum 12 weeks (7)(15) 

• In patients with various health conditions, omega-3s moderately decreased serum CRP, as well as IL-6 and TNF-α with a smaller effect. (5)
• Compared to placebo, omega-3 supplementation decreased total serum cortisol by 19% and IL-6 levels by 33% during a stressful event, and CRP by ~30%, IL-6 by ~22%, and TNF-α by ~16% in patients with chronic kidney disease undergoing hemodialysis. (7)(15)

Probiotics
Probiotics1.6 × 109 CFU, total per day, minimum 8 weeks (8)(11)

• Prebiotics and probiotics modulate the intestinal microbiome and decrease oxidative stress and inflammation by increasing intestinal anaerobes and maintaining the integrity of the intestinal barrier. (6) 
• Compared to placebo, a multistrain synbiotic reduced TNF-α by ~6% and hs-CRP by ~10% in postmenopausal females with obesity and a history of hormone-receptor-positive breast cancer. (11) 
• Compared to placebo, Lactobacillus rhamnosus GG reduced IL1-Beta and lipopolysaccharide concentrations by ~ 35% and ~30%, respectively, in patients with CAD. (8)

Quercetin
Quercetin≥ 500 mg, total per day, minimum of 8 weeks (2)(9)(14)

• In individuals with chronic diseases, quercetin had a large effect on decreasing IL-6 and a smaller effect on decreasing serum CRP. (9) 
• Quercetin decreased TNF-α and IL-6 in females with polycystic ovarian syndrome. (14)
• Compared to placebo, quercetin increased serum TAC by ~20% in post-myocardial infarction patients. (2)

The following protocols were developed using only a,b,c-quality evidence
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References

1. Chen, L., Deng, H., Cui, H., Fang, J., Zuo, Z., Deng, J., Li, Y., Wang, X., & Zhao, L. (2018). Inflammatory responses and inflammation-associated diseases in organs. Oncotarget, 9(6), 7204–7218. https://doi.org/10.18632/oncotarget.23208 
2. Dehghani, F., Sezavar Seyedi Jandaghi, S. H., Janani, L., Sarebanhassanabadi, M., Emamat, H., & Vafa, M. (2021). Effects of quercetin supplementation on inflammatory factors and quality of life in post-myocardial infarction patients: A double blind, placebo-controlled, randomized clinical trial. Phytotherapy Research, 35(4), 2085–2098. https://doi.org/10.1002/ptr.6955 (B)
3. Dehzad, M. J., Ghalandari, H., Nouri, M., & Askarpour, M. (2023). Antioxidant and anti-inflammatory effects of curcumin/turmeric supplementation in adults: A GRADE-assessed systematic review and dose-response meta-analysis of randomized controlled trials. Cytokine, 164, 156144. https://doi.org/10.1016/j.cyto.2023.156144 (A)
4. Gorabi, A. M., Abbasifard, M., Imani, D., Aslani, S., Razi, B., Alizadeh, S., Bagheri-Hosseinabadi, Z., Sathyapalan, T., & Sahebkar, A. (2022). Effect of curcumin on C-reactive protein as a biomarker of systemic inflammation: An updated meta-analysis of randomized controlled trials. Phytotherapy Research, 36(1), 85–97. https://doi.org/10.1002/ptr.7284 (A)
5. Kavyani, Z., Musazadeh, V., Fathi, S., Hossein Faghfouri, A., Dehghan, P., & Sarmadi, B. (2022). Efficacy of the omega-3 fatty acids supplementation on inflammatory biomarkers: An umbrella meta-analysis. International Immunopharmacology, 111, 109104. https://doi.org/10.1016/j.intimp.2022.109104 (A) 
6. Lopes, R. de C. S. O., Balbino, K. P., Jorge, M. D. P., Ribeiro, A. Q., Martino, H. S. D., & Alfenas, R. D. C. G. (2018). Modulation of intestinal microbiota, control of nitrogen products and inflammation by pre/probiotics in chronic kidney disease: A systematic review. Nutricion Hospitalaria, 35(3), 722–730. https://doi.org/10.20960/nh.1642 (A)
7. Madison, A. A., Belury, M. A., Andridge, R., Renna, M. E., Rosie Shrout, M., Malarkey, W. B., Lin, J., Epel, E. S., & Kiecolt-Glaser, J. K. (2021). Omega-3 supplementation and stress reactivity of cellular aging biomarkers: An ancillary substudy of a randomized, controlled trial in midlife adults. Molecular Psychiatry, 26(7), 3034–3042. https://doi.org/10.1038/s41380-021-01077-2 (B)
8. Moludi, J., Kafil, H. S., Qaisar, S. A., Gholizadeh, P., Alizadeh, M., & Vayghyan, H. J. (2021). Effect of probiotic supplementation along with calorie restriction on metabolic endotoxemia, and inflammation markers in coronary artery disease patients: A double blind placebo controlled randomized clinical trial. Nutrition Journal, 20(1), 47. https://doi.org/10.1186/s12937-021-00703-7 (C)
9. Ou, Q., Zheng, Z., Zhao, Y., & Lin, W. (2020). Impact of quercetin on systemic levels of inflammation: A meta-analysis of randomised controlled human trials. International Journal of Food Sciences and Nutrition, 71(2), 152–163. https://doi.org/10.1080/09637486.2019.1627515 (A)
10. Proctor, M. J., McMillan, D. C., Horgan, P. G., Fletcher, C. D., Talwar, D., & Morrison, D. S. (2015). Systemic inflammation predicts all-cause mortality: A glasgow inflammation outcome study. PloS One, 10(3), e0116206. https://doi.org/10.1371/journal.pone.0116206
11. Raji Lahiji, M., Zarrati, M., Najafi, S., Yazdani, B., Cheshmazar, E., Razmpoosh, E., Janani, L., Raji Lahiji, M., & Shidfar, F. (2021). Effects of synbiotic supplementation on serum adiponectin and inflammation status of overweight and obese breast cancer survivors: A randomized, triple-blind, placebo-controlled trial. Supportive Care in Cancer, 29(7), 4147–4157. https://doi.org/10.1007/s00520-020-05926-8 (B)
12. Sharif, S., Van der Graaf, Y., Cramer, M. J., Kapelle, L. J., de Borst, G. J., Visseren, F. L. J., Westerink, J., & SMART study group. (2021). Low-grade inflammation as a risk factor for cardiovascular events and all-cause mortality in patients with type 2 diabetes. Cardiovascular Diabetology, 20(1), 220. https://doi.org/10.1186/s12933-021-01409-0
13. Usharani, P., Mateen, A. A., Naidu, M. U. R., Raju, Y. S. N., & Chandra, N. (2008). Effect of NCB-02, atorvastatin and placebo on endothelial function, oxidative stress and inflammatory markers in patients with type 2 diabetes mellitus: A randomized, parallel-group, placebo-controlled, 8-week study. Drugs in R&D, 9(4), 243–250. https://doi.org/10.2165/00126839-200809040-00004 (B)
14. Vaez, S., Parivr, K., Amidi, F., Rudbari, N. H., Moini, A., & Amini, N. (2023). Quercetin and polycystic ovary syndrome; inflammation, hormonal parameters and pregnancy outcome: A randomized clinical trial. American Journal of Reproductive Immunology , 89(3), e13644. https://doi.org/10.1111/aji.13644 (B)
15. Valle Flores, J. A., Fariño Cortéz, J. E., Mayner Tresol, G. A., Perozo Romero, J., Blasco Carlos, M., & Nestares, T. (2020). Oral supplementation with omega-3 fatty acids and inflammation markers in patients with chronic kidney disease in hemodialysis. Applied Physiology, Nutrition, and Metabolism, 45(8), 805–811. https://doi.org/10.1139/apnm-2019-0729 (B)

​Disclaimer: The content provided is not intended to be for medical diagnosis or treatment, is not a substitute for your professional judgment, and is not meant to provide you medical or professional advice. Statements regarding dietary and other health care supplements have not been evaluated by the FDA, and are not intended to diagnose, treat, cure, or prevent any disease.

Proton pump inhibitors (PPIs) are a class of medications commonly prescribed to reduce stomach acid production and treat conditions like gastroesophageal reflux disease (GERD) and peptic ulcers. While effective, their long-term use may be associated with different nutrient deficiencies. (Eusebi 2017)

The mechanism of PPIs primarily involves reduced stomach acid production. However, stomach acid is important for absorbing certain nutrients. Vitamin B12 absorption, for example, depends on sufficient gastric acid to separate the vitamin from food proteins. Similarly, stomach acid is needed for the optimal absorption of minerals like iron, zinc, and magnesium. Reductions in stomach acid can also affect vitamin C absorption, which is sensitive to changes in gastric pH. Consequently, prolonged use of PPIs may impair the body’s ability to absorb these important nutrients, potentially leading to specific deficiencies and related health concerns such as an increased risk of infection, kidney damage, and dementia. (Eusebi 2017)

Assessing nutrient levels before and throughout the course of PPI therapy, with subsequent tailored supplementation based on these findings, may benefit patients using PPI medications. (Eusebi 2017)

​You can find the following recommended supplements at https://us.fullscript.com/welcome/spokane-wellness

Vitamin C
Vitamin C

• Maintenance: 90 mg per day (Office of Dietary Supplements n.d.)(U.S. Food & Drug Administration 2016)
• Correct deficiency: 200–500 mg per day of liposomal vitamin C (Davis 2016)

 

• A one-month course of 40 mg per day of omeprazole reduced plasma vitamin C levels in both Helicobacter pylori positive and negative individuals independent of dietary intake, indicating decreased bioavailability of the vitamin due to increased gastric pH. (Henry 2005)
• When combined with dietary nitrate intake, omeprazole significantly decreased the gastric juice ascorbate/nitrite ratio, potentially increasing the risk of gastric cancer due to elevated levels of carcinogenic N-nitroso compounds. (Mowa 1999)

Vitamin B12
Vitamin B12

• Maintenance: 2.4 mcg per day (U.S. Food & Drug Administration 2016)(Office of Dietary Supplements n.d.)
• Correct deficiency: 1,000–2,000 mcg per day of methylcobalamin (Wang 2018)

 

• Two or more years’ supply of PPIs was associated with a 65% increased risk for vitamin B12 deficiency compared to non-users. Doses more than 1.5 PPI pills per day were more strongly associated with vitamin B12 deficiency than were doses less than 0.75 pills per day. (Lam 2013)
• A 2021 cohort study examined 3,299 older adults. Participants taking higher PPI doses (≥30 mg per day) for more than six months had a significantly greater prevalence (21%) of vitamin B12 deficiency. (Porter 2021)
• A retrospective cohort study reported a significant association between the chronic use of PPIs and the presence of anemia, showing a decrease in hematological values in PPI users. (Sarzynski 2011)

Iron
Iron

• Maintenance: 18 mg per day of ferrous bisglycinate (U.S. Food & Drug Administration 2016)(Office of Dietary Supplements n.d.)
• Correct deficiency: 325–650 mg per day of ferrous bisglycinate (equivalent to 105–210 mg elemental iron) (Baird-Gunning 2016)

 

• There was a significant association between PPI use and the development of iron deficiency anemia (IDA) in patients with celiac disease. (Hawkins 2023)
• PPIs directly impaired iron metabolism by increasing hepcidin levels, which inhibited iron absorption through the suppression of duodenal ferroportin. (Hamano 2020)
• In a retrospective cohort study, chronic use of PPIs was significantly associated with a decrease in hemoglobin and hematocrit levels, suggesting an increased risk of iron-deficiency anemia. (Sarzynski 2011)

Magnesium
Magnesium

• Maintenance: 420 mg per day (U.S. Food & Drug Administration 2016)(Office of Dietary Supplements n.d.)
• Correct deficiency: 500–600 mg per day in divided doses (Agus 1999)

Elevated doses of magnesium may induce loose stools, necessitating the adoption of the bowel tolerance method.

• Long-term PPI use was significantly associated with hypomagnesemia in hospitalized adult patients. (Kim 2015)
• A 2011 FDA report stated that prolonged use of prescription PPIs may lead to low serum magnesium levels, which can result in adverse events, such as muscle spasms, irregular heartbeat, and seizures, and might necessitate the discontinuation of the drug in about one-quarter of the cases if magnesium supplementation alone does not resolve the issue. (FDA 2015)
• Hypomagnesemia was identified in 65 of 305 (21.3%) of participants taking PPIs for one year or longer, and the incidence increased as the age and duration of use increased. Patients using omeprazole had significantly lower magnesium levels than those using pantoprazole, rabeprazole, esomeprazole, and iansoprazole. (Yoldemir 2021)
• Long-term use of PPIs may cause severe hypomagnesemia, often accompanied by hypocalcemia and hypokalemia, which may lead to serious clinical issues such as arrhythmias. (Hoorn 2010)

Zinc
Zinc

• Maintenance: 11 mg per day (U.S. Food & Drug Administration 2016)(Henderson 1995)
• Correct deficiency: 20–50 mg per day, depending on severity, for six months (Henderson 1995)

 

• Long-term use of PPIs significantly reduced the absorption of supplemental zinc, leading to lower systemic zinc levels compared to healthy controls not using PPIs. (Farrell 2011)
• In an in-vitro and in-vivo study, the PPI drug pantoprazole suppressed the production of key immune-regulating cytokines IFN-γ and IL-2 in T cells by altering zinc distribution and downregulating the expression of Zip8 and transcription regulators pCREB and CREMα, suggesting that the use of pantoprazole may negatively affect the immune response. (Liu 2023)

Evidence ratingThe following protocols were developed using only a,b,c,d-quality evidence
Learn more about our rating scale
References

1. Agus, Z. S. (1999). Hypomagnesemia. Journal of the American Society of Nephrology, 10(7), 1616–1622. https://doi.org/10.1681/asn.v1071616 
2. Baird-Gunning, J., & Bromley, J. (2016). Correcting iron deficiency. Australian Prescriber, 39(6), 193–199. https://doi.org/10.18773/austprescr.2016.069 
3. Davis, J. L., Paris, H. L., Beals, J. W., Binns, S. E., Giordano, G. R., Scalzo, R. L., Schweder, M. M., Blair, E., & Bell, C. (2016). Liposomal-encapsulated Ascorbic Acid: Influence on Vitamin C Bioavailability and Capacity to Protect against Ischemia–Reperfusion Injury. Nutrition and Metabolic Insights, 9, NMI.S39764. https://doi.org/10.4137/nmi.s39764 
4. Eusebi, L. H., Rabitti, S., Artesiani, M. L., Gelli, D., Montagnani, M., Zagari, R. M., & Bazzoli, F. (2017). Proton pump inhibitors: Risks of long‐term use. Journal of Gastroenterology and Hepatology, 32(7), 1295–1302. https://doi.org/10.1111/jgh.13737 
5. Farrell, N. (2011). Proton pump inhibitors interfere with zinc absorption and zinc body stores. Gastroenterology Research. https://doi.org/10.4021/gr379w 
6. Frequently asked questions for industry on Nutrition Facts Labeling requirements. (2016). In U.S. Food & Drug Administration. department of health and human services.  https://s3.amazonaws.com/public-inspection.federalregister.gov/2016-11867.pdf 
7. Hamano, H., Niimura, T., Horinouchi, Y., Zamami, Y., Takechi, K., Goda, M., Imanishi, M., Chuma, M., Izawa-Ishizawa, Y., Miyamoto, L., Fukushima, K., Fujino, H., Tsuchiya, K., Ishizawa, K., Tamaki, T., & Ikeda, Y. (2020). Proton pump inhibitors block iron absorption through direct regulation of hepcidin via the aryl hydrocarbon receptor-mediated pathway. Toxicology Letters, 318, 86–91. https://doi.org/10.1016/j.toxlet.2019.10.016 
8. Hawkins, S., Nighot, M., Dalessio, S., Zhu, J., Morris, N., & Clarke, K. (2023). Proton pump inhibitor use and iron deficiency anemia in celiac patients. Digestive Diseases, 42(1), 25–30. https://doi.org/10.1159/000534800 
9. Henderson, L. M., Brewer, G. J., Dressman, J. B., Swidan, S. Z., DuRoss, D. J., Adair, C. H., Barnett, J. L., & Berardi, R. R. (1995). Effect of intragastric pH on the absorption of oral zinc acetate and zinc oxide in young healthy volunteers. JPEN, Journal of Parenteral and Enteral Nutrition/JPEN. Journal of Parenteral and Enteral Nutrition, 19(5), 393–397. https://doi.org/10.1177/0148607195019005393 
10. Henry, E. B., Carswell, A., Wirz, A., Fyffe, V., & Mccoll, K. E. L. (2005). Proton pump inhibitors reduce the bioavailability of dietary vitamin C. Alimentary Pharmacology & Therapeutics, 22(6), 539–545. https://doi.org/10.1111/j.1365-2036.2005.02568.x 
11. Hoorn, E. J., Van Der Hoek, J., De Man, R. A., Kuipers, E. J., Bolwerk, C., & Zietse, R. (2010). A case series of Proton Pump Inhibitor–Induced Hypomagnesemia. American Journal of Kidney Diseases, 56(1), 112–116. https://doi.org/10.1053/j.ajkd.2009.11.019 
12. Kim, S., Lee, H., Park, C. H., Shim, C. N., Lee, H. J., Park, J. C., Shin, S. K., Lee, S. K., Lee, Y. C., Kim, H. Y., & Kang, D. R. (2015). Clinical predictors associated with Proton Pump Inhibitor–Induced Hypomagnesemia. American Journal of Therapeutics, 22(1), 14–21. https://doi.org/10.1097/mjt.0b013e31829c4c71 
13. Lam, J. R., Schneider, J. L., Zhao, W., & Corley, D. A. (2013). Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12Deficiency. JAMA, 310(22), 2435. https://doi.org/10.1001/jama.2013.280490 
14. Liu, W., Jakobs, J., & Rink, L. (2023). Proton-Pump inhibitors suppress T cell response by shifting intracellular zinc distribution. International Journal of Molecular Sciences, 24(2), 1191. https://doi.org/10.3390/ijms24021191 
15. Mowat, C., Carswell, A., Wirz, A., & McColl, K. E. (1999). Omeprazole and dietary nitrate independently affect levels of vitamin C and nitrite in gastric juice. Gastroenterology, 116(4), 813–822. https://doi.org/10.1016/s0016-5085(99)70064-8 
16. Office of Dietary Supplements – Iron. (n.d.). https://ods.od.nih.gov/factsheets/Iron-HealthProfessional/ 
17. Office of Dietary Supplements – magnesium. (n.d.). https://ods.od.nih.gov/factsheets/Magnesium-HealthProfessional/ 
18. Office of Dietary Supplements – Vitamin B12. (n.d.). https://ods.od.nih.gov/factsheets/VitaminB12-Consumer/ 
19. Office of Dietary Supplements – Vitamin C. (n.d.). https://ods.od.nih.gov/factsheets/VitaminC-Consumer/ 
20. Office of Dietary Supplements – Zinc. (n.d.). https://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/ 
21. Porter, K. M., Hoey, L., Hughes, C. F., Ward, M., Clements, M., Strain, J., Cunningham, C., Casey, M. C., Tracey, F., O’Kane, M., Pentieva, K., McAnena, L., McCarroll, K., Laird, E., Molloy, A. M., & McNulty, H. (2021). Associations of atrophic gastritis and proton-pump inhibitor drug use with vitamin B-12 status, and the impact of fortified foods, in older adults. ˜the œAmerican Journal of Clinical Nutrition, 114(4), 1286–1294. https://doi.org/10.1093/ajcn/nqab193 
22. Research, C. F. D. E. A. (2017, August 4). FDA Drug Safety Communication: Low magnesium levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs). U.S. Food And Drug Administration. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-low-magnesium-levels-can-be-associated-long-term-use-proton-pump 
23. Sarzynski, E., Puttarajappa, C., Xie, Y., Grover, M., & Laird-Fick, H. (2011). Association between proton pump inhibitor use and anemia: a retrospective cohort study. Digestive Diseases and Sciences, 56(8), 2349–2353. https://doi.org/10.1007/s10620-011-1589-y 
24. Wang, H., Li, L., Qin, L. L., Song, Y., Vidal-Alaball, J., & Liu, T. H. (2018). Oral vitamin B12versus intramuscular vitamin B12for vitamin B12deficiency. Cochrane Library, 2018(3). https://doi.org/10.1002/14651858.cd004655.pub3
25. Yoldemir, Ş. A., Ozturk, G. Z., Akarsu, M., & Ozcan, M. (2021). Is there a correlation between hypomagnesemia linked to long-term proton pump inhibitor use and the active agent? Wiener Klinische Wochenschrift, 134(3–4), 104–109. https://doi.org/10.1007/s00508-021-01834-x

Disclaimer: The content provided is not intended to be for medical diagnosis or treatment, is not a substitute for your professional judgment, and is not meant to provide you medical or professional advice. Statements regarding dietary and other health care supplements have not been evaluated by the FDA, and are not intended to diagnose, treat, cure, or prevent any disease.

Incorrect use of a proper back pack can be just as damaging as using an improper back pack. Our growing children use their back packs for many years. Repetitive loading of heavy back packs combined with poor ergonomics can be a source of dysfunction in their body and can lead to chronic back and shoulder pain. Smart choices now are important to your child's health long after their school days are gone.

Signs that your child's back pack is inappropriate for them or that they are wearing the pack incorrectly include:

• Headaches at the base of their skull
• Neck pain or pain between their shoulder blades
• Red marks on their shoulders
• Shoulders rolled forward
• Stomach sticking out 
• Hips rolled forward
• Numbness in their arms or hands

When purchasing a new back pack one should look for:

• A lightweight bag which is the same length as your child's torso.
• A back pack that sits no higher than the top of your child's shoulders and no lower than the hip bones.
• Wide (at least 2") adjustable padded straps that do not cut into their arms or armpits.
• Chest strap
• Waist strap
• A padded back with many compartments to evenly distribute the weight

Maintain regular adjustments with your chiropractor to detect and correct spinal problems before they cause pain and dysfunction in your growing child.

Additional tips for proper back pack ergonomics:

• Place heavy items closest to their back.
• Place odd shaped items outside to prevent poking into their back.
• Elementary students should no exceed 10% of their body weight.
• Junior and Senior High students should not exceed 15% of their body weight.
• Place the back pack on their back from a table height or lift properly with the knees.
• Adjust the straps so the bottom of the back pack lies in the curve of their low back.
• Check the back pack regularly for unnecessary items.
• Carry extra books or lunches in hand.
• Use the waist strap to redistribute 50-70% of the bag's weight off their upper body and onto their pelvis.
• Have their back pack assessed with your local chiropractor for appropriateness.

When a patient is diagnosed with a lumbar disc herniation, what is the best treatment?

Best Answer: Both conservative and surgical options are backed by research. Though the ultimate decision of which route to choose should be made by the patient based on their individual goals and needs after an honest discussion with their surgeon.

Now let's talk!

Lumbar disc herniations are a very common condition affecting the spine of young and middle-aged folks. The incidence of lumbar disc herniations within certain populations has been estimated to be greater than 50% though often the disc herniations is asymptomatic, meaning without symptoms. A disc “injury” quite often happens in the absence of any pain and you don’t even know about it. Medicare estimates that spending on lumbar discectomy procedure, a surgery to remove disc material, exceeds $300 million annually. Back pain related disorders may or may not always be the result of a disc herniation but are a common cause of disability nonetheless. The American health care system spends over $1 billion annually to address back pain conditions. 

The structure of the disc is composed of circular, basket woven-like annular fibers made of collagen, proteoglycans, and a variety of regenerative cells that surround a gel like structure called the nucleus pulposus. The disc serves to dissipate forces exerted on the spine as well as give space between the vertebra above and below the disc so the nerves have room to exit the spine. As we age, the disc tends to lose water content and height. This loss of hydration and disc collapse can increase strain on the annular fibers which may lead to bulging, a protrusion or extrusion of disc material that would be seen as a herniation. The joint made up between the two vertebral bones and disc is called the intervertebral joint. It is classified as a fibrocartilage joint and can also be referred to as a symphysis joint, similar to the pubic symphysis of the pelvis. If you know anything about symphysis joints, you know that they are EXTREMELY STRONG and they certainly don't slip out of place, giving the impression that discs are inherently weak. It takes about 740lbs of force to compress the disc height 1mm in young subjects and 460lbs of force to compress the disc height 1mm in older subjects. End story is that discs are VERY strong. 

With all that said, back pain may still occur due to disc bulging without pressure on the spinal canal or nerve roots. However back pain with radiculopathy can occur when pressure or irritation of the extruded disc material contacts the thecal sac or lumbar nerve roots. The pain commonly felt with radiculopathy can be felt as electrical, shooting, pins and needles, numbness, tingling, or weakness into the leg. Often patients will experience this as "Sciatica". Sciatica is a description of any of the symptoms above felt in the leg as a result of pressure or irritation of the specific nerve roots levels of L4, L5, or S1. The good news is that 90% of patients with lumbar disc herniations will improve without substantial medical intervention like surgery. Too many people think that once you have a disc herniation (or disc bulge), that you’ve got it for life. Discs have the ability to heal. A patient should not be fearsome of low back pain, even if pain is caused by a disc injury.

Regarding treatment, the research supports both conservative management and surgical intervention as viable options for the treatment of lumbar disc herniation even when radiculopathy is present. Surgical intervention may result in faster relief of symptoms and earlier return to function, although long-term results studies show similar outcomes regardless of type of management. It should be noted that contrary to popular belief of some including surgeons, the size of a lumbar disc herniation does not predict outcomes or the need for surgery. Research indicates from many studies, multiple medical association position statements, and my own clinical experience treating these disorders validates this notion. This is consistent with findings from a 2010 study which found that even massive disc herniations can successfully be treated conservatively. In fact, on several occasions patients with nearly complete spinal canal narrowing were successfully managed without surgery, some as great as 85.1%. Literature suggests that less than 10% of disc herniation cases ultimately require surgery.

The typical patient with lumbar disc related pain will often present to their primary care physician first. However research supports chiropractors being a great first contact for these patients. In fact, medical costs may significantly be reduced when a patient visits a chiropractor first. Initial management of these disorders should include regular movement within a patient's tolerance, exercise guidance, manipulation of the spine, proper nutrition and supplementation, and adequate sleep. A patient should not be told to completely rest. Many of these patients are able to continue lifting. In most instances, radicular symptoms will go away within six weeks. Patients with symptoms that persist beyond six weeks will often be referred for advanced imaging like magnetic resonance imaging (MRI) in order to identify the area of disc pathology and to determine if they are also candidates for more invasive treatments like  injection or surgery.

If you are suffering from back pain, please click the link below to request an appointment!

Thirty-one million Americans have low back pain at any given time.1 One half of all working Americans admit to having back symptoms each year. 2 One third of all Americans over age 18 had a back problem in the past five years severe enough for them to seek professional help. 3  And the cost of this care is estimated to be a staggering $50 Billion yearly–and that’s just for the more easily identified costs!4
These are just some of the astounding facts about Americans and their miserable backs! Is there any wonder why some experts estimate that as many as 80% of all of us will experience a back problem at some time in our lives?5
Because back problems are this common it’s probably going to happen to you too! Shouldn’t you find out what to do about it before it happens rather than after? Why wait until you’re hurting to learn about your treatment options?
When you’re hurting you may not give this important decision the time and attention it needs to make the best choice. Here are the facts about manipulation as a treatment for back problems:
Manipulation is one of several established forms of treatment used for back problems. Used primarily by Doctors of Chiropractic (DCs) for the last century, manipulation has been largely ignored by most others in the health care community until recently. Now, with today’s growing emphasis on treatment and cost effectiveness, manipulation is receiving much more widespread attention. In fact, after an extensive study of all currently available care for low back problems, the Agency for Health Care Policy and Research–a federal government research organization–recommended that low back pain suffers choose the most conservative care first. And it recommended spinal manipulation as the ONLY safe and effective, DRUGLESS form of initial professional treatment for acute low back problems in adults!6 Chiropractic manipulation, also frequently called the chiropractic adjustment, is the form of manipulation that has been most extensively used by Americans for the last one hundred years.7 Satisfied chiropractic patients already know that DCs are uniquely trained and experienced in diagnosing back problems and are the doctors most skilled in using manipulation for the treatment of back pain and related disorders.8 As a public service, the American Chiropractic Association (ACA) urges you to make an informed choice about your back care. To learn more about the federal government’s recommendations and how chiropractic manipulation may help you, contact a Doctor of Chiropractic in your area.
References:1. Jensen M, Brant-Zawadzki M, Obuchowski N, et al. Magnetic Resonance Imaging of the Lumbar Spine in People Without Back Pain. N Engl J Med 1994; 331: 69-116.
2. Vallfors B. Acute, Subacute and Chronic Low Back Pain: Clinical Symptoms, Absenteeism and Working Environment. Scan J Rehab Med Suppl 1985; 11: 1-98.
3. Finding from a national study conducted for the American Chiropractic Association. Risher P. Americans’ Perception of Practitioners and Treatments for Back Problems. Louis Harris and Associates, Inc. New York: August, 1994.
4.This total represents only the more readily identifiable costs for medical care, workers compensation payments and time lost from work. It does not include costs associated with lost personal income due to acquired physical limitation resulting from a back problem and lost employer productivity due to employee medical absence. In Project Briefs: Back Pain Patient Outcomes Assessment Team (BOAT). In MEDTEP Update, Vol. 1 Issue 1, Agency for Health Care Policy and Research, Rockville, MD, Summer 1994.
5.In Vallfors B, previously cited.
6.Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December, 1994.
7.The RAND Corporation reported from its analysis of spinal manipulation research literature that 94% of all spinal manipulation is performed by chiropractors, 4% by osteopaths, and the remainder by medical doctors.

Did you just sprain your ankle? I did recently. It hurts! Ankle sprains occur so often that sometimes it can be easy to overlook helpful treatment strategies to accelerate the healing because, well, they will heal on their own, right?

Ankle sprains are the most common lower extremity injury in sport. The most common is an inversion sprain where the foot rolls under the inside portion of the ankle. There are eversion sprains and diastasis (aka "high ankle") sprains, but these are less common. ​

Now more than ever it seems the world wants effective means by which to naturally boost the immune system. We've already learned a lot about what strengthen our immunity before this pandemic and even more afterwards.

What we know is that functional impairment of antigen-specific T cells is a hallmark of chronic infections and viral disease. 

There are many considerations for boosting immunity and T cell function. Supplements most notable for this are:

• Vitamin D3 with K2
• magnesium
• zinc
• selenium
• melatonin

In addition to supplementation, staying hydrated and eating well are usually the first things people think about when wanting to boost their immune system. I mean, you are what you eat right. But what ways naturally boost the immune system that goes beyond what you put in your mouth? Here are 4 ways to boost the immune system naturally that doesn't involve diet and nutrition:

1. Reduce stress - when your mental health is attacked, inflammation is seen throughout the body because of your hormonal response to cortisol. Chronic inflammation causes an imbalance in cell function and can lead to illness and disease. Managing your stress levels by practicing mindfulness techniques, speaking to a licensed counselor, journaling your thoughts, socializing with friends, receiving a massage, reading a book, reducing screen time,  or enjoying a favorite activity can all help keep your immune system functioning properly.(1,2,3)
2. Restful sleep - most of us have experienced a time in our life when we consistently got less and less sleep and were more prone to getting sick. Adequate rest will significantly impact the ability to fight illness and infections. Our bodies need sleep to recover from everyday stressors, whether that be mental or physical. Aim for 7 hours of actual sleep time if you are an adult, 8-10 hours for adolescents, and 14 hours for young children and infants. (4,5,6)
3. Exercise - moderate intensity exercise will place a healthy amount of oxidative stress on your body that causing your immune system to adapt over time to this stress and slowly strength immune cellular function. It can be tricky because chronic high-intensity exercise can also cause enough stress to the immune system resulting in an unfavorable outcome of suppressing the immune system. Brisk walking regularly is one of the most often studied forms of exercise that shows consistent results for boosting the immune system. (7,8,9)
4. Chiropractic adjustments - okay this one I'm certain I will need research to support. Last thing I need is someone saying I said Chiropractic adjustments cure COVID-19. I am not saying that. In no way shape or form am I suggesting that chiropractic can cure, treat, prevent, or mitigate COVID-19 because the evidence to substantiate such a claim does not exist. The practice of chiropractic however focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health.  There is a growing body of evidence showing a positive relationship between the chiropractic adjustments, the nervous system and the immune system. (10,11,12,13,14,15)

​Want more tips and tricks on keeping your body healthy and strong? Hit us up at Gaitway Chiropractic @ Spokane Wellness in Spokane, Wa. 509-466-1366

References:

1. ​​Dhabhar FS. Effects of stress on immune function: the good, the bad, and the beautiful. Immunol Res. 2014 May;58(2-3):193-210. doi: 10.1007/s12026-014-8517-0. PMID: 24798553.
2. Cohen S, Janicki-Deverts D, Doyle WJ, Miller GE, Frank E, Rabin BS, Turner RB. Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk. Proc Natl Acad Sci U S A. 2012 Apr 17;109(16):5995-9. doi: 10.1073/pnas.1118355109. Epub 2012 Apr 2. PMID: 22474371; PMCID: PMC3341031.
3. ​Carlsson E, Frostell A, Ludvigsson J, Faresjö M. Psychological stress in children may alter the immune response. J Immunol. 2014 Mar 1;192(5):2071-81. doi: 10.4049/jimmunol.1301713. Epub 2014 Feb 5. PMID: 24501202.
4. Prather AA, Janicki-Deverts D, Hall MH, Cohen S. Behaviorally Assessed Sleep and Susceptibility to the Common Cold. Sleep. 2015 Sep 1;38(9):1353-9. doi: 10.5665/sleep.4968. PMID: 26118561; PMCID: PMC4531403.
5. Besedovsky L, Lange T, Haack M. The Sleep-Immune Crosstalk in Health and Disease. Physiol Rev. 2019 Jul 1;99(3):1325-1380. doi: 10.1152/physrev.00010.2018. PMID: 30920354; PMCID: PMC6689741.
6. Nagai N, Ayaki M, Yanagawa T, Hattori A, Negishi K, Mori T, Nakamura TJ, Tsubota K. Suppression of Blue Light at Night Ameliorates Metabolic Abnormalities by Controlling Circadian Rhythms. Invest Ophthalmol Vis Sci. 2019 Sep 3;60(12):3786-3793. doi: 10.1167/iovs.19-27195. PMID: 31504080.
7. ​Simpson RJ, Kunz H, Agha N, Graff R. Exercise and the Regulation of Immune Functions. Prog Mol Biol Transl Sci. 2015;135:355-80. doi: 10.1016/bs.pmbts.2015.08.001. Epub 2015 Sep 5. PMID: 26477922.
8. Abd El-Kader SM, Al-Shreef FM. Inflammatory cytokines and immune system modulation by aerobic versus resisted exercise training for elderly. Afr Health Sci. 2018 Mar;18(1):120-131. doi: 10.4314/ahs.v18i1.16. PMID: 29977265; PMCID: PMC6016983.
9. ​Khosravi N, Stoner L, Farajivafa V, Hanson ED. Exercise training, circulating cytokine levels and immune function in cancer survivors: A meta-analysis. Brain Behav Immun. 2019 Oct;81:92-104. doi: 10.1016/j.bbi.2019.08.187. Epub 2019 Aug 24. PMID: 31454519.
10. Fidelibus, J.C., An overview of neuroimmunomodulation and a possible correlation with musculoskeletal system function. J Manipulative Physiol Ther, 1989. 12(4): p. 289-92.
11. Teodorczyk-Injeyan, J.A., H.S. Injeyan, and R. Ruegg, Spinal manipulative therapy reduces inflammatory cytokines but not substance P production in normal subjects. J Manipulative Physiol Ther, 2006. 29(1): p. 14-21.
12. Lohman, E.B., et al., The immediate effects of cervical spine manipulation on pain and biochemical markers in females with acute non-specific mechanical neck pain: a randomized clinical trial. J Man Manip Ther, 2019. 27(4): p. 186-196.
13. Teodorczyk-Injeyan, J.A., et al., Elevated Production of Nociceptive CC Chemokines and sE-Selectin in Patients With Low Back Pain and the Effects of Spinal Manipulation: A Nonrandomized Clinical Trial. Clin J Pain, 2018. 34(1): p. 68-75.
14. Kovanur-Sampath, K., et al., Changes in biochemical markers following spinal manipulation-a systematic review and meta-analysis. Musculoskelet Sci Pract, 2017. 29: p. 120-131.
15. Teodorczyk-Injeyan, J.A., et al., Enhancement of in vitro interleukin-2 production in normal subjects following a single spinal manipulative treatment. Chiropr Osteopat, 2008. 16: p. 5. 

​Disclaimer
The Content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition.