Dr. Beecher, the anesthesiologist, returned to his position at Harvard after his military tour of duty and in 1955 published “The Powerful Placebo” in the AMA Journal. Multiple prospective trials noted the curative effectiveness of placebos. Moreover, Beecher found that the effects of many current drugs were no better than placebo. However, the pharmaceutical products wee all associated with risk of side effects whereas the placebos were not.

By 1962 even the FDA was willing to acknowledge “placebo effect”. As such, new pharmaceutical products have to outperform placebos in at least two authenticated trials. We are not yet out of the woods. Pharmaceutical companies market physicians and now directly to patients via television and other media, grossly downplaying costs, adverse effects, and effectiveness compared to alternatives.

If your doctor offered you pill #1 that is effective in 5/10 cases and perfectly safe always versus pill #2 that is effective in 9/10 cases but may cause ulcers, dizziness, blindness, and in rare cases death, which would you choose? Just listen to the disclaimer statements in direct to consumer pharmaceutical related television advertising, then tell your doctor that it would probably safer (and maybe just as effective) to prescribe so sugar pills for my pain.

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However, early descriptions date back to the 17th century. It is recognized now as a neurologic movement disorder of the limbs, often associated with a sleep complaint.

RLS is often simply a component of another condition or a toxicological response of medications and consumables.

Pathophysiology

The pathogenesis of RLS is unclear, although there are numerous non-unifying hypotheses yielding limited effective treatments for specific subsets of cases. RLS also tends to run in families. However, so does a preference to cornbread over white bread run in some families. Although, some would suggest existence of genetic relationship, humans share 99.9 percent common genetic code. As such, the genetic profile (family history) is most important in relation to cultural/family behavior, environmental exposures, discrepancies in resources and their affects upon genetics triggers.

Frequency

Although frequency of incidence may be suggested in some literature, defining a set of signs and associated diurnal symptom tendencies does not make for an adequate disease definition. As such, true frequency is unclear. Severity of symptoms in patients with RLS ranges can be remarkably variable, worse in older patients probably related to other concurrent neurovascular disease. Health status matched men and women appear to me equally affected.

Diagnosis

Pins and needles, numbness and tingling, and insect crawling sensations accompanied by uncontrollable urge to  move the lower extremities with occasional short-lived periods of forceful dorsiflexion of the feet. Physical examination is generally normal.

Treatment

Idiopathic familial association is offered as an explanation in more than fifty percent of cases. Just as “success” has been described by many as the juncture between preparedness and opportunity, disease precipitation due to family history generally implies engagement in common family behaviors, lifestyle choices, choices in living environments, work and other comparable factors that concordantly adversely interacts with pre-existing sensitive biology.

As such, to suggest familial association is to ask the patient to hunt for familial commonalities. Other recognized associations are:

• Lumbar disc herniation
• Anxiety,
• Situational stress,
• Excessive fatigue,
• Iron deficiency,
• Peripheral neuropathy (numerous causes),
• Dietary deficiencies: iron, folic acid, magnesium, B-12,
• Lyme disease,
• Sjogren syndrome,
• uremia,
• unclear hormonal imbalances of pregnancy,
• End-stage renal disease,
• hyperphosphatemia,
• Antidopaminergic drugs,
• diphenhydramine,
• tricyclic antidepressants,
• selective serotonin reuptake inhibitors (SSRIs),
• alcohol,
• caffeine,
• lithium,
• beta-blockers,
• caffeine overuse,
• and nicotine overuse.

The pathogenesis of RLS seems to involve so many possible mechanisms that one may wonder if it deserves to have an ICD code.  Particularly, it is important that both patients and clinicians recognize that the significant variety of mechanisms implies that no “one treatment fits all.” Moreover, the least toxic and invasive interventions (massage, warm baths, acupuncture, walking, stretching) are probably the best initial choices of in the absence of a definitive cause. Do no harm.

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Even simple decompressions may cost about thirty-thousand dollars in hospital and surgeon fees alone. These fees do not include subsequent costs of loss of productivity, medications, physical rehabilitation and pain management to address residuals. Concurrent fusions will create an additional sixty to ninety thousand dollars in surgical/hospital fees and extended post-surgical expenses.

Studies of patients undergoing fusions over the past five years also suggest that most patients demonstrated no pre-procedural objective findings suggestive of instability, meaning that fusions were not even indicated. Moreover, even when local procedure rates decline, hospitals often offset revenue by increasing hospitalization fees and aggressively co-marketing for performance of additional procedures along with surgical appliance manufacturers. In this multibillion-dollar industry, in July of 2006 Medtronic Inc. settled with the U.S. Justice Department in a whistle-blower case that included allegations of payments to surgeons to use its spine surgery products. While engaging in the typical denial of any wrongdoing in the cases, Medtronic also vowed to further strengthen its employee training and compliance systems regarding marketing practices.

Only recently did a spine surgeon at the UC Irvine found the [Surgical] Association for Medical Ethics to encourage surgeons to act on scientific evidence over vested interests. Fortunately, newer health care law requires surgical device manufacturers and others to file annual reports to the government on their financial ties to physicians.

Too many spinal surgeries are performed in the U.S., particularly fusions without valid support.  While complex surgeries are needed for some conditions, an open slot in the operating room schedule is not a valid reason. There is little agreement amongst medical professional about the best way to treat chronic lower back pain. However, in many cases data preceding surgery is not definitive regarding the most significant contributors to the pain. Patients should always seek alternatives to surgery for non-emergency procedures.

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Diagnosis of mechanical back pain in most allopathic or osteopathic medicine patients generally entails x-rays, and may eventually include CT/MRI evaluation. However, these studies only demonstrate structural “abnormalities” which are very often not responsible for the symptoms. Consider the numbers of people that believe that they need regular adjustment because they have been informed by non-radiologists that their spines are “out of alignment”. Diagnosis and treatment that is predominantly based upon radiographic “abnormalities” will result is a plethora of ineffective plans. Even worse, poor and exaggerated interpretation of radiographic data will cause some many to believe that they have some type of pathology that will persist. To the contrary, we must avoid premature use of unnecessary technologies and avoid expedient application of diagnostic labels that infer trauma and potential causes of neuralgia with the intent and/or effect of yielding convenient case labeling for billing, supporting insurance algorithm directed treatment plans and/or appeasing patients.

A precursor circumstance that immediately preceded the onset of back pain is frequently offered as the cause of the pain. More often than not, this “cause” is a label of convenience for the insurance or legal systems that may eventually be responsible for adjudicating issues of liability and impairment, particularly if the onset of pain occurred in a setting in which they have some fiduciary alliance.

The etiology of back pain is often multifactorial. At times, patients may not be able or willing to address all contributing factors. Moreover, others with limited liability in the case may wish intervention to be focused upon elements of the case for which they deem themselves to be responsible as if they could be precisely microtomed away from the remainder of the pathology and associated symptoms. The clinician and patient should be prepared to acknowledge and address all factors if possible.

Factors may include:
1. age,
2. gender,
3. ethnicity regarding behaviors associated with social customs,
4. diet including vitamins and mineral supplements,
5. weight and fitness,
6. activities of daily living and recreation,
7. personal habits (e.g., smoking, alcohol consumption),
8. rigorous work,
9. pre-existing disease and pathology, and
10. prior injuries.

You are highly likely to experience lumbar pain at some time in your life. The majority of you will experience reversible mechanical pain. However, as contributors to symptoms are often multifactorial, be prepared to address them all.

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While some might question this approach, how many times have you accepted a job offer from a complete stranger, believing that you would be paid in two weeks? You not only had faith in the stranger’s offer, but you went home and declared your success to family and/or friends. Moreover, by announcement, and hearing your own words spoken, you affirm the statements as true, reinforcing your confidence that you actually have check coming soon.

A limited example of how Christians might employ this strategy to medicine is demonstrated by a combination of Isaiah 53:5 and Romans 10:17, engaging scripture to address their healing. The rest of you should simply verbally affirm that pain has no place in your life, never referring to it as “my pain.” Rather, suggest that you are presently experiencing pain, as it resolves via means including your word power.

He is a rather stoic individual, but has found that his back pain symptoms have persisted.  Sometimes he felt better than prior to our initial visit, at other times worse, the pain ranging from usually slight to occasionally moderate. Overall, he now reports that his pain has not worsened since last seen, particularly since stopping the prescription medications. However, he has slowed the pace at which he exercises, including having completely ceased golfing. He is now four months out since the date of injury. Jim reports that his diabetes and arthritis are stable. He is becoming frustrated by persistence of symptoms and prolonged diminished function relative to activities of daily living.

He elected to forsake prescription medications because of the strong adverse effects (gastrointestinal pain, alternating diarrhea and constipation, drowsiness and impaired function).  He continued continue the acetaminophen up to 3 times per day, by preference.

He participated in nine sessions of physical therapy, instructed regarding posture and independent exercises, and has been working out in the gym twice a week.

On physical examination Jim is 5’ 10”, 195 pounds, and of moderate build. He reports tenderness just to the right and left of midline at the L4-L5 level, with minor spasm and withdrawal. He has no other tenderness in the lower back, buttocks, hips or lower extremities. He demonstrates diminished flexion today, stopping at fingertips reaching just below the knees. However, his lower extremity circulation, sensation and reflexes were normal..

Assessment

1. Subacute low back (lumbar) pain with probable left L4 nerve root irritation
2. History of arthritis of hands and shoulders
3. History of Type 2 diabetes
4. Early dysthymia related to 1.

Discussion

We acknowledge that symptoms have grossly persisted. Objective findings on physical examination are remarkably unchanged. Reconsidering the original history, we are presently working under the assumption that age plus the frequent rotational torque force on the patient’s spine from his pastime (golf) resulted in some degenerative changes and stress injuries in the lumbar spine. The patient may have torn some of the fibrocartilage in the posterior external rings of his discs and precipitated early arthritic changes in the associated facet joints.

X-rays identified no significant objective findings. There is still no evidence of neurological dysfunction, or other systemic symptom, thereby as yet no evidence of need for performance of an MRI.

Treatment

1. The patient is still averse to using traditional, prescription medications, but concedes to use acetaminophen as needed. However, we agree to add a supplemental, alternative approach to analgesia.
2. Unloading pressure on the lumbar discs and facets daily will provide additional relief and encourage circulation.
3. The patient’s frustration has not yet risen to the level of depression. However, he is experiencing mild dysthymia. As such, I recommended increased engagement in pleasant distractions.
4. We recommend care regarding diet so as to avoid gaining more weight.
5. We will follow-up in approximately eight weeks.

Please contact us regarding specific recommendations of alternative approaches to analgesia, unloading pressure on the lumbar discs and facets, evolving psychological symptoms and diet challenges.

Traditional western treatments are variable in effectiveness, usually delivered via a combination of NSAIDs, opiates, and anticonvulsants or antidepressants. These pharmaceutical products are all associated with their own side effects and in combination may yield significant gastrointestinal distress, altered mental acuity and diminished motor skills, tolerance (requirement of ever increasing product volume/strength for effectiveness) and dependence.

Cannabis has been recognized as an effective analgesic for both focal and neuropathic pain since the late 1800’s. Chemical receptors have been identified in our body with which the cannabanoid compounds interact. These receptors are distinct from opiate receptors, thereby accounting for the additive effectiveness of cannabis in persons already using other prescription analgesics. In fact, our body also produces its own endocannabanoids (some similar to endorphins) that act on these cannabanoid receptor sites. The existence of the endocannabanoids and associated receptors provides an explanation for the effectiveness of various marijuana strains with differing chemical constituent concentrations.

Sativex®, a cannabis based product has been approved in Great Britain for the neuropathic pain occurring in Multiple Sclerosis. In the U.S., Cesamet® (nabilone) and Marinol® (dronabinol) are already available as synthetic THC for appetite enhancement in end-stage AIDS and post-chemotherapy patients. However, they have very limited chemical effectiveness compared to the full spectrum effect of cannabanoids in natural plant sources. Moreover, Cesamet® and Marinol® use in pain management is considered “off-label”, thereby not supported by most health insurance

Given the variable and sometimes markedly limited effectiveness of combinations of NSAIDs, opiates, anticonvulsants and antidepressants in pain management, traditional western physicians should be excited about an alternative, very effective natural plant product, cannabis. However, most clinicians sublimate their awareness of ongoing problems of opiate abuse and diversion as well as minimize the importance of adverse effects of all of these products because of their traditional biases.

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TENS involves placement of sticky stimulus pads (electrodes) over or near the sites of pain, the pads attached to wires from a source of electrical stimulation. The TENS units function via a combination of means including overexciting the pain receptor nerves, inhibiting their ability to send off pain signals, blocking pain signals in route to the brain and causing release of natural pain relieving chemicals from our bodies (endorphins, enkephalins, and dynorphins).

High frequency and low frequency TENS has slightly different effects. As such, working with multi- frequency units is preferable. Satisfactory response to specific frequencies and pulse patterns differs from person to person. Optimal settings vary and are determined by trial and error. Electrode positioning is often based upon a combination of recommendations from professionals and source materials that accompany the TENS units and subsequent to personal experience.

Medical complications arising from use of TENS are rare. However, there are a few contraindications for TENS use including concurrent use of fixed electrical stimulators (e.g., pacemaker), pregnancy and others. Although TENS are very simple devices, please contact your primary health provider regarding the safety of TENS use for you as part of a plan to address your low back (or other) pain.

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Consider pain as a blank page and interventions as various sized hole punches that punch out the pain. Note that none of the punches are large enough to cover the entire page. In fact, most of the punches are specific for only a localized portion of the page. As such, after addressing the relevant portion of the page, each tool serves no additional function via increased application (e.g., such as increased frequency, force of application). That said, after maximizing the amount of treatment that you can tolerate or wish to engage in, you need to apply a complementary, alternative intervention.

One frequent result of back muscle injury is isolated band of hyper-stimulated muscles. These significantly spasmed muscles pinch nerves, triggering local and referred pain. The identifiable specific locations are referred to as trigger points. Trigger point manual intervention will relieve this pain.

You can learn to work with a partner or employ a complementary approach by which you may self-apply the technique.
Contact us with specific questions about this technique. Click through to acquire supportive materials.

He presented to his personal doctor with symptoms of local left paramidline L4-L5 pain with occasional referral to the left buttocks. Jim reported no lower extremity weakness, pain, burning or pins & needles sensations in the lower extremities. He reported no change in his sense of lower extremity sensation or balance/coordination.

Jim reported that he manages his diabetes by diet and exercise. He uses an occasional additional over the counter (OTC) acetaminophen tablet (e.g., Tylenol) given his arthritis in his hands and shoulders. He believes that he is experiencing some constipation and stomach distress related to his use of the ibuprofen and hydrocodone. He reported to work full time at a desk job.

On physical examination Jim was 5’ 10”, 185 pounds, and of moderate build. He reported tenderness just to the left of midline at the L4-L5 level, with no spasm or referral of symptoms to other areas. He had no other local tenderness in the lower back, buttocks, hips or lower extremities. He demonstrated full range of motion and his lower extremity circulation, sensation and reflexes were normal. He brought the lumbar x-ray films taken previously. They were of reasonable quality and demonstrated good vertebral alignment, disc spacing and evidence of only mild degenerative/arthritic changes.

Assessment

1. Subacute low back (lumbar) pain with probable left L4 nerve root irritation
2. History of arthritis of hands and shoulders
3. History of Type 2 diabetes

Plan

1. Prescription medications were discontinued because neither has been effective and both are likely contributors to the combined gastrointestinal symptoms.
2. He was allowed to continue the acetaminophen up to 3 xs per day.
3. He may be experiencing some irritation of the lumbar intervertebral facet joints with regards to which some mechanical unloading of them may be helpful. As such, he was referred to physical therapy for exercise instruction including use of a foam roller and gym ball for self-traction. Inversion to 15 degrees for 2 – 3 minutes, twice daily was also discussed.
4. He was to continue working out at the gym.
5. He could apply topical alternation heat and ice.
6. He would continue his normal work, but it was recommended that he get up from his chair, stand, walk and stretch his low back hourly.

Neither his history nor physical examination suggested the need for additional radiology examinations, other diagnostic testing or other specialty referral. Jim and his doctor agreed on the plan and a follow-up appointment in one month.

Of marked significance is that the doctor and patient “agreed” on the plan and Jim was not just passive and submissive in his health care process.