Issue 1, 2013
Magazine for members of Ontario Osteopathic & Alternative Medicine Association 1
- What is Alternative Medicine - What is Osteopathy - Chronology of Osteopathy - Regulation Osteopathy in Ontario - Osteopathic visit - Different kinds of Osteopathic Medicine - Method R. Volla - What is Naturopathic Medicine - Low back and slipped disk
Svetlana Daryanina is a Homeopath (a membership of the Homeopathic Medical Council of Canada); Master of Alternative Medicine (a membership of the Ontario Osteopathic & Alternative Medicine Association). Svetlana Daryanina has 25 years of experience like a doctor of alternative medicine in the Scientific Center of Clinical and Experimental Medicine SB RAMS, Novosibirsk, Russia. She was graduated from Novosibirsk State Medical University (Bachelor of Science, Doctor of Medicine) and got PhD Diploma from Supreme Attestation under the Council of Ministers of the USSR. Svetlana Daryanina is author of published articles and books in the area of herbs therapy, electro-acupunctural method and health. She holds several patents in diagnostic practice and botanical medicine.
2100 Steeles Ave. W., Suite 202, Vaughan, ON. L4K 1Z3 Tel: 416-736-9365, www.osteoassociation.com, firstname.lastname@example.org 2
Ontario Osteopathic and Alternative Medicine Association About the Ontario Osteopathic and Alternative Medicine Association The Ontario Osteopathic and Alternative Medicine Association is a not-for-profit organization based in Toronto, Ontario. The association’s scope includes foreign accreditation, fraud prevention, ongoing professional development, and discipline for unprofessional and dangerous conduct. Our goal with respect to alternative medicine is to ensure that only the finest quality of services, with the utmost professionalism is provided to patients within Ontario. We manage to do so by employing a Board of Directors, who review and critique the professional conduct of all of our members. We strive to influence practitioners of alternative medicine in Ontario in furthering their education and delivering a high-quality and ethical service to their clients. We also have an active complaints and disciplinary process, which addresses the concerns of dissatisfactory patients.
History of the Association The Ontario Osteopathic and Alternative Medicine Association was founded in early 2005 by a small group of practitioners. On November 30th, 2007, the association was officially recognized for meeting the criteria of the City of Toronto’s list of approved Professional Holistic Associations (PHS). The association was then listed in the Toronto Municipal Code: Chapter 545, Appendix L. The association’s member list expanded to include various practices over time, including chiropractic, acupuncture, osteopathy, and therapeutic massage. The association currently regulates the professional conduct of over 100 practitioners of alternative medicine within Ontario. The Ontario Osteopathic and Alternative Medicine Association looks forward to welcoming individuals with extraordinary scientific and medical abilities. Osteopathic Manual Practitioners DO (MP) vs. Doctors of Osteopathy (D.O.) In Canada, osteopathic education and training can only be obtained through a Diploma of Osteopathic Manual Practice (DO(MP)) Doctor of Osteopathy (D.O.) degrees, education, and training are unavailable in all of Canada. The only notable difference between D.O. and DO (MP) licensed practitioners is the authority to prescribe medication or perform surgery. DO (MP) licensed practitioners cannot prescribe medication or perform surgery. However, they may assess and treat patients using an Osteopathic philosophy and manual techniques, just like D.O. licensed practitioners. 3
Alternative Medicine Alternative medicine is a primary health care system using therapies that support the person’s selfhealing potential. It is the embodiment of a tradition in medicine that could rightfully be called “vitalistic”, a tradition reaching back to Hippocrates, the revered Greek physician, who has been called the father of Western Medicine. The vitalistic tradition is based on the premise that the body has an inherent ability to heal, a premise referred to in Latin as “Vis medicatrix nature” (healing power of nature), and that the human being is a dynamic creation of body, mind, and spirit, more than the sum of its parts. The human body can adapt and respond to the challenges of life. There are some interrelated principles of that inform the practice of alternative medicine from assessment
and diagnosis to prognosis and treatment, including patient care and case management. Principles of Alternative Medicine: - First, do not harm - Co-operate with the healing powers of nature - Address the fundamental causes of disease - Heal the whole person through individualized treatment - Teach the principals of healthy living - Practice preventive medicine Alternative Therapy Modalities: - Botanical medicine - Homeopathy - Traditional Chinese Medicine - Acupuncture - Physical Medicine - Hydrotherapy - Massage therapy - Osteopathy - Manual therapy - Clinical Nutrition - Lifestyle Counseling These therapies tend toward a traditional natural approach. The role of the physician or practitioner in this tradition of medicine is to support the self-healing ability of the whole being. The most recent statistical information from Health Forced Ontario indicates that for most of health professions: - Employment grew at an above-average rate. - Hourly wages are above average, and the rate of wage growth is close to the average. - The unemployment rate is below average. - Employment forecasts are generally positive as well. The employment growth rate will likely be above average because of ongoing trends--a growing and aging population that requires more health services, new technologies that improve the ability to diagnose disease, increased government funding for health care, and Canadians with health care insurance that covers more services.
What Is OSTEOPATHY? Even though osteopathy appeared 140 years ago, it is a young and much promised area of medicine which popularity is gained from year to year. Contrary to manual therapy, osteopathy is much more multipurpose, and its technology deeper and more comprehensive because it is aimed at addressing the causes of the disease, not only at correcting the spine. Osteopathy is designed to help the body to "understand itself" and find the inner resources to normalize its operations. In other words, osteopathy is a method of treatment by hand effects on the musculoskeletal system, internal organs, and the central nervous system, which eliminates the mechanical dysfunction, includes self-regulation mechanisms of the body, and activates body`s internal resources. How is the treatment In osteopathy doctor`s hand defines the diagnosis of diseases and the treatment. Osteopathy`s treatment does not use pills or scalpels, and its methods are safe and effective. Organs and tissues of healthy people have a certain shape, density, and temperature. When patients have pathological disorders, organs` characteristics are varying: the organs may move, grow and become denser. A professional osteopath will catch these changes conducting inspections. The whole points of his caring and trained fingers that light touch recognize problem areas in the body. The sooner patient had access to a doctor, the faster and easier he or she can eliminate the source of the problem and provide his or her body the right way out of the crisis. Something that can be easily corrected in the first hours after birth, in a few years requires a long and lasting impact. Treatment session is analogous to the chiropractor`s treatment: patient lies on a special couch and the doctor works with his or her body by different touching. Deep knowledge of anatomy and physiology allows osteopath find the cause of the patient`s problems and pains. Doctor`s hands can feel that sometimes do not identify by medical devices: muscle tension, ligament disorders, and rhythm in the internal organs. Already knowing these problems, osteopath can easily fix them, relax muscles, remove inflammation, open the blocked channel, increase the blood flow, and thereby restore normal functioning of an organ. After several sessions
of "soft manipulation" the whole system of the body comes into order. Moreover, to achieve the result it is not necessary to use force, as it often happens in the session a chiropractor, you should know how to do. Closed door can be opened by force leaning on her shoulder and knocking the door. And you can just insert and turn the key. It is very gentle techniques, and doctor activates self-control and recovery. Immediately after the session, the patient cannot feel any change in his or her body. And this is connected with the fact that the body needs time to adjust to the new conditions of being. It may not happen immediately, but after treatment the person starts to feel the "comfort" in the body, he or she will feel that something is changed, will keep an eye on this process. Patient can very quickly realize that it is the positive effects improved the quality of his or her life. Due to above information, someone decides that this treatment is phony. Indeed, many have become accustomed to manual therapy sessions, where binding is active and even tighter squeeze on the human body. With full responsibility we can say that osteopathy is NOT a pseudoscience. In fact, it is a very practical and logical science based on the laws of biomechanics. In addition, manual therapy is just one aspect of osteopathic school. Osteopathy is the next, a new stage of manual medicine. This is a completely new technology in medicine, based on the simple knowledge of mechanical processes to understand how there is a movement of our structures and how they interact during this movement. Of course, the treatment of each patient is individual. Do not assume that osteopathy is panacea for all ills. Unfortunately, it is powerless when the patient has serious violations of chemical processes in the body or cancer. In many countries where this method has been around for a long time, osteopath often acts as a family doctor, who removes the stress, relieves headaches, notices the violation of the child's posture, and regulates the work of the spine. Essentially osteopathy is a kind of a therapy with a wide profile. Very often our body does not need any medical or surgical intervention and appreciates the help of a professional, and finds the most effective way to use benefits of osteopathy for its own recovery.
CHRONOLOGY OF OSTEOPATHY Osteopathy was founded in the late 1880’s by Doctor Andrew Taylor Still, who discovered the significance of living anatomy in health and disease, and realized that optimal health is possible only when all of the tissues and cells of the body function together in harmonious motion. He established that disease could have its origins in slight anatomical deviation from normal and proved restore health by treating the body with his hands, naming his innovative approach: osteopathy. At the age of ten, young Andrew Still suffered from frequent headaches with nausea, so he constructed a rope swing between two trees and lay down using the rope for a swinging pillow. He got a good result, because his headache all gone. He continued to use this ‘treatment’ successfully every time he had a headache. Later, Dr. Still considered his ‘rope swing treatment’ of headaches, and realized ... “I had suspended the action of the great occipital nerves, and given harmony to the flow of the arterial blood to and through the veins...I have worked from the days of a child...to obtain a more thorough
knowledge of the workings of the machinery of life, in producing ease and health.” He intended a totally new medical system that acknowledges the relationships of the body, mind, emotions and spirit. Dr. Still developed a very practical way of treating people using just his hands. Still saw this self-correcting potential as a cornerstone of his osteopathic philosophy. Still did extensive anatomic and physiologic study and developed treatment protocols consistent with his studies, termed osteopathic manipulation. He expressed himself in terms of mechanical and electrical principle consistent with the science of his day. His research and clinical observations led him to believe that the muscular-skeletal system contained all the elements needed to restore health, if properly stimulated. By correcting problems in the body’s structure by manual techniques, the body’s ability to function and heal itself could be greatly improved. He also promoted preventative medicine and endorsed the philosophy that Osteopaths should treat the whole patient not just the disease. As a result of his clini-
cal success, he was encouraged to teach others his J.M. Littlejohn, the first dean of the American School methods and in 1892 opened the American School of of Osteopathy, subsequently returned to the United Osteopathy in Kirksville Missouri. Success of his stu- Kingdom and in 1917 opened the British School of dents leads to the rapid spawning of other schools. Osteopathy in London. Progression of the spread of When combined with appropriate use of present day osteopathy in the British Isles and the European conmedical therapeutics, osteopathy offers a profound tinent proceeded from both streams. In Belgium the contribution to the practice of medicine. By 1910 it first osteopaths given training and degrees from the was recommended, through sponsored reports, that ESO opened offices but did not organize as the Belosteopathic colleges within the gian Society of Osteopathy and United States adopt a system of Research in Manual Therapy until higher education, licensing and 1976, later to reform as the Belgian regulation. By 1930, through a Society of Osteopaths in 1986. staggered transition, the AmeriOsteopathy was exported to Ruscan osteopathic profession adoptsia in 1989 by Viola Frymann with ed a medical model of osteopatha cranial emphasis. However, The ic education that incorporated Russian School of Osteopathy was all conventional diagnostic and also assisted by the ESO, BSO and therapeutic practices of medicine the CEO. Education largely follows including pharmacology, surgery the British model. Although many and obstetrics. For this reason, all graduated have a prior medical graduates from osteopathic coldegree, osteopathic training does leges or osteopathic universities in not grant general medical privilegthe United States are fully licensed es. In Germany, since the 1990’s the medical practitioners and are reckinesiology and medical models ognized internationally as Osteohave competed as the prototype pathic Physicians. Early political acof osteopathic training and practivity and response to the pressure tice. Such has also been the activAndrew Taylor Still, ity in France, Sweden, Norway, and for medical reform led American osM.D., D.O. teopaths to become licensed as phyFinland. In recent years osteopathy sicians and progressively integrated (August 6, 1828 – December 12, has been introduced with inclusion 1917) is considered the father a significant portion of medical sciof schools and associations in Porof osteopathy and ence. Later activity in the 1950’s led tugal, Italy, and Austria. In Canada, osteopathic medicine. to parity of osteopathic physicians the largest training stream for osteowith medical doctors. As a result, ospaths, the College Osteopathiques teopaths are variable committed to de Montreal, complies with the Engthe practice of the manual aspect of the tradition. lish model. The first self-identified college of manual The rest of the world, including Europe, Asia, Can- (non-medical) osteopathy in Canada opened in 1981. ada, and the countries of the southern hemisphere, There are now 8 manual osteopathy schools in Canahas not adopted this medical model of Osteopathy. da, teaching in Halifax, Montreal, Quebec City, ToronInstead their curriculum focuses primarily on the man- to, Hamilton, Vancouver, Ottawa, London, Winnipeg, ual application of traditional osteopathic philosophy Calgary and Edmonton. Two of the schools; National and principles. Israel may be an exception. In 1917, Academy of Osteopathy & the National University of Osteopathy took root in Europe thanks to Dr. Martin Medical Sciences offer both campus based as well as Littlejohn, DO, a student of Dr. Still and a professor at online osteopathic education across Canada. Austrahis osteopathic school. Littlejohn founded the Brit- lia and New Zealand have developed an osteopathic ish School of Osteopathy, which is still active today. profession largely blending English and American In France, the origin of Osteopathy has been traced features. At present, osteopathy has evolved in a culback to Major Stirling in 1913. Very early, (1906) Eng- turally appropriate form into Japan and has been inlish osteopaths trained in America returned home. troduced in practice in at least 22 countries. 7
The Regulation of Osteopathy in Ontario The regulation of Osteopathy in the province of Ontario is complicated by several factors. This complication is due to the recognition of the title Osteopathic Physician, by The College of Physicians and Surgeons of Ontario. Osteopathic Physicians are those individuals who have trained in the United States and who hold a medical degree from a college approved by the American Osteopathic Association. In addition to being licensed physicians, training in osteopathic medicine is not available in Canada. U.S. is trained Doctors of Osteopathic Medicine/osteopathic physicians are licensed as full physicians with the provincial Colleges of Physicians and Surgeons. The Ontario Medicine Act 1991 states that “No person other than a member (registered with the College of Physicians & Surgeons) shall use the titles “physician” or “surgeon”, a variation or abbreviation or an equivalent in another language, 1991, c. 30, s. 9 (1).” and “No person other than a member shall hold himself or herself out as a person who is qualified to practise in Ontario as a physician or surgeon or in a specialty of medicine, 1991, c. 30, s. 9 (3).” Membership in the College of Physicians and Surgeons requires that members are physicians trained in the full scope of medical practice. Similar title protection laws have been enacted in Alberta and British Columbia. Manual (non-medical) osteopathy (also known as European style osteopathy, traditional osteopathy or osteopathic manual practice) is not a regulated profession in Canada yet. Although, The College of Physicians and Surgeons of Ontario recognizes Osteopathic Physicians, the manual practice of Osteopathy is not regulated in Ontario. There are more than 8 schools that teach manual osteopathy in many locations across Canada (National University of Medical Sciences - Toronto, Ontario, Canadian College of Osteopathy - Toronto, Ontario, Canadian College of Osteopathy - Winnipeg, Manitoba, Canadian Academy of Osteopathy - Hamilton, Ontario, Canadian Osteopathic College - Toronto, Ontario, Collège d’Études Ostéopathiques - Montreal, Quebec, Collège d’Études Ostéopathiques - Halifax, Nova Scotia, Collège d’Études Ostéopathiques - Vancouer, British Columbia Centre Ostéopathique du Québec - Montréal, Quebec, National Academy of Osteopathy (NAO teaches manual osteopathy in 64 cities in 32 countries including Toronto, Montreal, Vancouver, Edmonton, Calgary, & Ottawa), Southern Ontario College of Osteopathy - Mississauga, Ontario and etcetera). 8
Different kinds of Osteopathy Osteopathy is a philosophy, science and art of health management. Osteopathy is divided into three areas: - Structural osteopathy solves the problems of the musculoskeletal system - Visceral osteopathy impacts on the internal organs - Cranial osteopathy adjusts the ratio of bone and soft tissue structures of the head Structural Osteopathy works with the musculoskeletal system (bones, muscles, ligaments and joints) and solves some problems (relief the pain in the back, stimulation mental and physical activity, increase resistance to stress conditions, development ridding of chronic fatigue syndrome). Visceral Osteopathy works with the internal organs. It applies to normalize of the liver and intestine, to improve digestion and metabolism, to eliminate of gynecological problems, to treat of chronic diseases of the genitourinary system, to prevent of varicose veins. Cranial osteopathy affects on bone and soft tissue, structures of the skull. This is the most amazing part of osteopathy. Osteopathic method cranial therapy - is the relaxation of the deep structures of the brain. If these structures are in a constant state of tension, they begin to compress the brain and the skull. Method of cranial therapy can relax these structures and protect people from pain. This method is completely safe, but only in the hands of a specialist. Osteopath follows the natural movements of the skull`s bones, makes minimal impact. Organs and tissues of healthy people have a certain shape, density, and temperature. When they have pathological disorders, these characteristics vary: the organs may move, grow and become denser. Osteopath`s hands are able to catch the changes that are not painful and are not recognized by the equipment. Osteopaths know the rules that a well-balanced body will function properly for a long time. Therefore, it is recommended to go to the osteopath regularly as a preventative inspection to the dentist. Indications for children (effects of birth injuries and operations, encephalopathy, minimal brain dysfunction, neuroses, attention deficits and behavioral psychomotor delay, speech and intellectual development, neurological problems, headaches, hypertension-hydrocephalic syndrome, incorrect posture (scoliosis, torticollis), dysfunctions of the musculoskeletal system, flatfoot, frequent colds and gastrointestinal diseases. Indications for adults (effects of injuries and surgeries, diseases of the musculoskeletal system, neuralgia, pain in the joints and spine, gynecological diseases (chronic inflammation of the appendages, adhesions in the pelvis, hormonal disorders of the ovaries, painful menstruation cycle disorders, some forms of infertility), headaches, intracranial hypertension, asthma, internal diseases). Contraindications for osteopathy: - Some organic and mental illness - Severe infections - Tumor - Thrombosis Osteopathic medicine is effective at any age and at any stage of life. 9
The Osteopathic Medical Visit, Typical Examination First, the doctor will ask for a complete medical history, including specific questions about the history of the pain episodes and prior treatments. Information that is also important to the osteopathic physician is whether there has been any significant past trauma, falls or accidents, even if they occurred a long time ago. The reasoning behind this is that it is not uncommon for such an event to cause a number of compensatory changes in the musculoskeletal system over time. The pain of today may be the result of the body’s inability to compensate further. The examination, in addition to a targeted neurological and orthopedic assessment, will emphasize a complete structural functional evaluation of the musculoskeletal system. This typically includes: - Visual assessment of posture, spine, muscles, balance and gait - Physical palpation of the back, legs and arms to assess the quality and motion of tissues and structural make-up
- Movement of the back, legs and arms, checking for joint restriction and/or pain One goal of the examination is to determine whether there exist one or more relevant somatic dysfunctions which would require treatment. The term “somatic dysfunction” is an accepted diagnosis according to the Hospital Adaptation of the International Classification of Disease. It denotes the impaired or altered function of related components of the somatic (body framework) system, including the bones, joints, muscles and fascia, and related blood vessels, lymph vessels and nerves. Osteopathic Manipulative Treatment (OMT) With the patient sitting or lying down on a table, the doctor of osteopathy will gently apply a precise amount of manual pressure in a specific direction. The pressure is applied either directly in the affected areas or at some distance away. It is used to put the tissues at ease (relaxed) or to engage them at their functional limit in order to affect the following: - Treat structural and tissue abnormalities (vertebrae, muscles, myofascial structures, etc.) - Relieve joint restriction and misalignment - Restore muscle and tissue balance - Promote the movement of bodily fluids After a thorough examination and diagnosis, treatment may include osteopathic manipulative treatment (OMT). The number of OMT treatments required varies with each patient and condition. While there exist no “hard and fast” rules as to the duration and exact number of treatments required, objective improvement in pain and/or functional abilities should become apparent in as few as five to six consecutive treatments, unless there are prominent complicating factors. Initially, treatment may be twice a week for two to four weeks (in rare cases, treatment may be three times a week). Follow-up treatments typically are no more frequent than once or twice a week for a certain period of time (not open-ended). The Osteopath will re-examine the patient during each of the visits to see if there is appropriate progress and to set realistic time-based goals for treatment. Objective parameters are used to determine if there is adequate progress: - Improvement in the patient’s function (ability to work, activities of daily living, ability to move about and perform certain activities, etc.) - The reduction in need for pain medication. - The patient’s report of his or her pain perception The goal of treatment is to enhance the patient’s ability to function independently with minimal or no pain, while maintaining this independence through appropriate home exercises, nutrition and life-style. Accordingly, in a chronic pain situation and as long as function is maintained, treatment is generally reduced to a minimum yet reasonable number of visits, but may require a limited set of additional treatments during an episode of exacerbation.
Electro-acupunctural Diagnostic Method by Reinhold Voll The Quintessence of the Method R. Voll method - a method of electro-acupuncture diagnosis and treatment of the human body based on the measurement of the “energy potential” of biologically active points (BAP) and on the correlation between electro conductive properties of measurement points and the functional state of the related organs and body systems. The method combines acupuncture, homeopathy, botanical medicine and electrotherapy. The Derivation of the Method Specific points on the body associated with the condition and functioning of the organs and systems, have been known for at least 3 - 4 thousand years. They were used in the treatment of in ancient China. Eastern medical schools have established a link between the internal organs and BAP, located on the skin. By acting on these points using different methods ancient physicians achieved remarkable outcomes. Based on this knowledge, R. Voll in collaboration with engineer Werner in 1953 continued to research and created the instrument for electro-diagnosis and treatment of the human body, in which, by measuring the electrical parameters of BAP, he could assess the condition of the body. For several years, the method has gained wide popularity. In 1966, R. Voll was awarded the gold medal of the Vatican. And in 1975-1978 received the highest state awards of Germany developed a method electro-acupuncture diagnosis. The Potentials of the Method 1. Diagnosis of functional and structural condition of all organs and systems. R. Voll method to diagnose pre-
clinical stages of the disease when the symptoms are not clearly expressed or absent, helps decipher unclear clinically complicated cases. 2. Finding hidden foci of infection. Without further analysis and laboratory method reveals the presence of infections, even in latent form. 3. Identification of adverse effects on the body of various toxins. 4. Analyse and control over the effectiveness of any treatment. R. Voll method allows us to analyze the changes that occur in the body due to various dosage forms and hardware treatment. 5. Selection and testing of allopathic and homeopathic medicines. With this method, you can individually select effective for the human form and dose of drugs, does not cause side effects. Benefits of the Method 1. Adaptability of the method. This method of diagnosis and treatment can be applied to all age groups. 2. The effectiveness of the method. R. Voll method to diagnose and successfully treat a wide range of diseases. 3. Painless method. Indications body in BAP “removed” without breaking the skin and without a strong physical impact. 4. Efficiency of the method. During 1, 5 - 2 hours conduct a full diagnosis of the organism and the rate of primary treatment. The method of R. Voll combines the traditional and modern medicine and has invaluable advantages. 11
Naturopathic medicine is a distinct primary health care system that blends modern scientific knowledge with traditional and natural forms of medicine. The naturopathic philosophy is to stimulate the healing power of the body and treat the underlying cause of disease. Symptoms of disease are seen as warning signals of improper functioning of the body, and unfavourable lifestyle habits. Naturopathic Medicine emphasizes disease as a process rather than as an entity. Treating both acute and chronic conditions, naturopathic treatments are chosen based on the patient – their physiological, structural, psychological, social, spiritual, environment and lifestyle factors. In addition to diet and lifestyle changes, natural therapies including botanical medicine, clinical nutrition, hydrotherapy, homeopathy, naturopathic manipulation and traditional Chinese medicine/ acupuncture, may also be used during treatments. In Canada, the naturopathic medical profession’s infrastructure includes accredited educational institutions, professional licensing, national standards of practice, participation in many federal health committee initiatives, and a commitment to state-of-the-art scientific research. Today, more people than ever before are seeking and benefiting from naturopathic medical care and the number of naturopaths is growing at record rates to accommodate this increased demand. Currently there are naturopaths practicing in every province and territory in Canada. The more than 1,875 naturopaths across the country continue to be an emerging answer to Canada’s health care concerns. Naturopaths are experiencing greater recognition as health care practitioners and as experts in the field of natural and preventive medicine. They provide leadership in natural medical research and enjoy increasing political influence. Positions for naturopaths are opening up in hospitals, multi-disciplinary clinics and specialized health centres across Canada. In Canada there are five provinces that have naturopathic regulations: British Columbia, Alberta, Saskatchewan, Manitoba and Ontario. The Naturopath Act of 2008 grants title protection for naturopaths in the province of Nova Scotia. Most of the other provinces are also in the process of seeking regulation. In this new century, the naturopathic profession finds itself well positioned in health care. With more and more research supporting the therapies used by naturopaths, the public demand for greater choice and increased access to more natural approaches to health care, naturopathic medicine is poised to make the transition from “alternative” medicine to “mainstream” medicine. 12
Many people have low back pain that keeps on coming back. Often, an exact cause cannot be determined and the pain goes away on its own after a few days or a couple of weeks. But if you have low back pain that extends further down through your leg and into your foot, it may be a sign of a slipped disk, or â€œherniated diskâ€?. This kind of pain, which extends into the extremities, is called sciatica. This fact sheet is about low back and leg pain caused by a slipped disk. You can learn about what happens when you do have a slipped disk, what treatments are available, and when surgery might be a good idea. More detailed
information on treating chronic low back pain can be found in this fact sheet about that topic. Sciatica can be very unpleasant. But the good news is that if a slipped disk is in fact causing the pain, symptoms usually subside in less than six weeks on their own in 90 out of 100 people with this problem. If the pain lasts longer than six weeks, it is less and less likely that it will go away on its own or that nonsurgical treatment will be any help. Surgery may then be an option depending on the circumstances. What is a slipped disk? The spine is made up of a chain of >> 13
bones called the vertebrae. The front part of each of the vertebrae is called the vertebral body. Soft spinal disks are found between the vertebrae. The disks have a hard, multilayered casing and a gel-like center (nucleus pulposus). It is thanks to these disks that the spine is flexible and we are able to lean forward or to turn our upper body from side to side. They also absorb shocks that are transferred to the spine when we are running or jumping, for instance, having a slipped disk means that one of the spinal disks is bulging beyond the edges of the vertebral bodies above and below it. There are three types of slipped disk: - Prolapse: the disk is bulging out between the vertebrae, but its outermost layer is still intact. - Extrusion: here there is a tear in the outer layer of the spinal disk, causing spinal disk tissue to leak out. The tissue that has come out is still connected to the disk. - Sequestration: spinal disk tissue has entered the spinal canal and is no longer directly attached to the disk. These categories reveal little about what symp14
toms occur or how severe they might be. Regardless of whether the tissue is deformed or has leaked out of the disk: a slipped disk can press against nerves and cause pain, or it may not cause any problems and remain undetected. Knowing what type of slipped disk someone has is, however, important for the choice of treatment and understanding how the condition might develop. What are the causes and symptoms of a slipped disk? In most people, slipped disks are the result of wear and tear on the body. Over the years, the spinal disks lose their elasticity: they retain less water, and become brittle and cracked. These changes are a normal part of aging, and already start happening when we are young. But not everyone do spinal disks age at the same pace. Very rarely an accident or very severe injury might also cause damage to a spinal disk and leave it herniated. Slipped disks in the lumbar region are the main cause of sciatica (sciatic pain). Sciatica describes pain that extends through one leg and down into the foot. This kind of pain may be caused by spinal disk tissue irritating a nerve root in the lumbar region. The
nerves that run through the spinal canal connect to the sciatic nerve at the pelvis: it is the sciatic nerve that runs down the legs. An irritated sciatic nerve can also cause pins and needles and numbness, besides being painful. As well as the typical radiating pain, a slipped disk can also lead to acute pain in the low back region. “Simple” back pain like this usually has a different cause, however, which is often not possible to clearly identify. A slipped disk does not always cause symptoms, though. Research in which adults without any back pain were examined using magnetic resonance imaging (MRI) showed this: More than 50 out of 100 people who had an examination had a bulging disk. In about 20 out of 100 of these people, the core of the disk had already broken through several layers of its casing or had even entered the surrounding tissue, but without causing any noticeable symptoms. Pain that extends down into the leg may also have a cause other than a slipped disk. The vertebrae can wear down with age and their shape might change. This can cause symptoms similar to those of sciatica. Muscle cramps and tension in the low back or in the buttocks can also irritate the sciatic nerve. Very rarely a tumor close to the spine is the cause. You can read about what warning signs might indicate that there could be more serious problems in “Low back pain: Warning signs of a serious cause”. How can the cause of back pain be determined? Answering a few questions from your doctor and a physical exam are usually enough to determine what is causing acute back pain. X-rays cannot be used to diagnose a slipped disk. Other imaging techniques such as MRI are only needed in rare cases, for instance if - there is numbness or paralysis symptoms in one or both legs, - the functioning of the bladder or bowel is impaired, - the pain is intolerable despite treatment, - severe symptoms remain for weeks at a time despite treatment, or - It is thought that another condition might be causing the pain, for example a tumor. It is therefore likely that your doctor has good reasons if he or she is cautious about what the examinations show: an exam using imaging may show a possible cause of back pain that actually has nothing to do with the symptoms. This kind of misdiagnosis can then result in unnecessary treatment that may itself be harmful.
What treatment options are available? If a slipped disk is causing the symptoms, they will most likely gradually go away without any treatment. Until they do, treatment to relieve pain can help to cope with the symptoms. Although having a slipped disc is quite a common problem, there is no evidence that certain treatments have a considerable effect on speeding up recovery. In 90 out of 100 people, sciatica symptoms go away within six weeks. About 10 out of 100 will have long-term symptoms. Non-surgical treatment options Most people with a slipped disk who have symptoms are offered “conservative” treatment, meaning that the treatment does not involve surgery. The main conservative options are: - Exercise, relaxation and positioning (legs raised) - Medication - Manual and physical therapy - Treatment methods based on traditional Asian medicine - Injections near the spine (injection therapy) - Exercise, relaxation and positioning It used to be common practice for people who had a slipped disk to be advised to stay in bed for one or two weeks. Nowadays, the advice given is quite different. Keeping active is often strongly recommended because remaining in a lying position for a longer time can make muscles and bones weaker, which can end up causing other problems. Research has shown that staying active instead of getting bed rest can help your mobility. However, whether people kept up with exercise or rested instead had no influence on the back pain itself in the trials. So it is a good idea to carry out your normal daily activities as the pain allows. Relaxation exercises may also be worth a try to help relieve back pain. Your psyche can influence how you perceive pain and how well you can cope with it. But if the pain is very severe there is sometimes simply no other way to deal with it than to lie down and find a position to put as little strain on your back as possible. Many people find it comfortable to lie on their back and rest their lower legs on any raised platform high enough to make their knees bend at a 90-degree angle. But it is important not to stay inactive for too long. It has also been established that exercise can be effective at preventing back pain from returning. You can find some more specific information on this in our research summary on >> preventing back pain. 15
Medications There are a number of different medications for relieving sciatica. Most of these are painkillers, but you can also take muscle relaxants and anti-inflammatory drugs. The following medications are the most commonly used, all of which are available without prescription when taken at a low dose: - Nonsteroidal anti-inflammatory drugs (NSAIDs): These painkillers are part of the same group as acetylsalicylic acid (ASA, or â€œAspirinâ€?). NSAIDs that may be an option for treating sciatica include - diclofenac, ibuprofen and naproxen. NSAIDs have a pain-relieving and anti-inflammatory effect. Because NSAIDs to some extent stop blood from clotting, they can cause bleeding. The bleeding may be mild, such as a nosebleed or bleeding gums, but there may also sometimes be more serious bleeding, for example in the stomach or bowels. In some cases NSAIDs can also cause stomach ulcers. NSAIDs may also impair the functioning of the kidneys. If you have asthma, cardiovascular disease or a stomach ulcer, it is a good idea to first ask your doctor before taking NSAIDs. It is also possible to inject NSAIDs into a muscle, but this is generally not very common nowadays. Using NSAIDs by injection most likely has no advantages over tablets or suppositories, but it may cause nerve damage, bleeding or inflammation at the site of injection. - Acetaminophen (paracetamol) is also a painkiller, but it is not part of the NSAID group. Acetaminophen is considered to be well tolerated and may, in particular, be an option for people who do not tolerate painkillers from the NSAID group. These might include people who have stomach problems or asthma. But high doses of acetaminophen can damage the liver and kidneys. The package insert advises adults not to take more than 4 grams (4000 mg) per day. This limit is equal to eight 500 mg acetaminophen tablets. Besides paying attention to the dose, it is important to make sure that you wait long enough before you take the next tablet. Prescription drug options include: - Muscle relaxants: These are tranquilizers taken to relax the muscles. Just like other psychotropic drugs, they can cause tiredness and drowsiness and can impair driving ability. Muscle relaxants can also impair the functioning of the liver and lead to complications in the stomach or bowels. Muscle relaxants >>
from the benzodiazepine group, for example tetrazepam, can lead to dependency if they are taken for longer than two weeks. - Anticonvulsants: These medications are typically used to treat epilepsy, but some are approved for treating nerve pain (neuralgia). Possible side effects include drowsiness and tiredness, which means they can impair driving ability. - Antidepressants: These are usually used for treating depression. Some of them are also approved for the treatment of pain. Possible side effects include nausea, dry mouth, low blood pressure, irregular heartbeat and tiredness. - Anticonvulsants and antidepressants are typically not used unless the symptoms last for a longer period of time or the painkillers do not provide enough relief. Manual and physical therapy Manual and physical therapy are also used to treat sciatica. Manual treatment may include massages and special grips for relaxing tense muscles or locked joints. Physical therapy uses heating and cool-
ing to relieve pain. These treatments are also called passive therapies, because patients do not have to take an active role in assisting the therapist. Common treatments include: - Massages: Various massage techniques are used to relax muscles and ease tension. - Heating and cooling: This includes the use of hot packs, a hot bath, going to the sauna or using an infrared lamp. Heat can also help relax tense muscles. Cold packs, like cold wraps or gel packs, are also used to help with irritated nerves. - Ultrasound therapy: Here the lower back is treated with sound waves. The small vibrations that are produced generate heat to relax body tissue. There is no overall proof that passive treatments speed up recovery or relieve pain especially well. Yet many people do find that heat or a massage is pleasant and relaxing. Treatment methods based on traditional Asian medicine include: - Acupuncture: In acupuncture the therapist sticks fine needles into certain points on the body
with the aim of relieving pain. - Reiki: Reiki is a Japanese treatment which aims to relieve pain by using specific hand placements. There are very few good-quality trials on these treatments. Acupuncture is the only approach for which there is weak evidence that it might relieve pain â€“ although this relief has been shown to be unrelated to where the needles are placed on the body. Injections near the spine (injection therapy) This therapy uses mostly local anesthetics and/or anti-inflammatory medications like corticosteroids (for example cortisone). These drugs are injected into the area immediately surrounding the affected nerve root. There are different ways of doing this: - In lumbar spinal nerve analgesia (LSPA), the medication is injected directly at the point where the nerve root exits the spinal canal. This has a numbing effect on the nerve root. - In lumbar epidural analgesia, the medications are injected into what is known as the epidural space (â€œepidural injectionâ€?). The epidural space surrounds the spinal cord and the spinal fluid in the spinal canal. This is also where the nerve roots are located. During this treatment the spine is monitored using computed tomography or X-rays to make sure that the injection is placed at exactly the right spot. Injections close to the spine can have side effects including bleeding, infection and nerve damage. A treatment involving many injections over a longer period of time may also lead to muscle weakness and is associated with radiation exposure. For this reason only a certain number of injections may be given within a particular time period. It is important to carefully consider having multiple injections of this type. Trials of these injection procedures have shown that they are able to relieve sciatica for several weeks. The people who were treated in the trials were able to go about their daily activities more freely. Rehabilitation The goal of rehabilitation is to improve symptoms and impairments resulting from a slipped disk, and strengthen the muscles in the back to improve the stability of the spine. Rehabilitation may include backstrengthening exercises, stretching and relaxation exercises, strength training and other measures. It is an option for people who have been greatly affected by their back pain and, for example, are unable to work. Inpatient rehabilitation may help after surgery too. Surgery >> Surgery is always done if the slipped disk 17
and the symptoms go away. Different surgical techniques may be used when operating on a slipped disk: - Open discectomy (microdiscectomy): “Open” discectomy is the most common procedure for operating on a slipped disk. Here the damaged part of the spinal disk is removed and the surgeon is able to see the area being operated on using a microscope. People who have this microsurgical procedure need a general anesthetic and have to stay in hospital for a few days. The risks of this procedure include bleeding, nerve damage and infection. A general anesthetic may lead to complications like breathing problems or circulation problems. - Endoscopic suris an emergency: for example, if the nerves are gery: Endoscopic surgery – also called keyhole sur>> so severely impaired that the bladder or the gery – uses very small instruments so that the procebowel is no longer functioning properly or cerdure will only require one small incision. This is done tain muscles have become very weak. Yet this is only to speed up recovery and prevent scars from forming, seldom the case. The far more common reason to because the scars may cause symptoms as well. In this have surgery is that it has not been possible to relieve type of operation, an endoscope is inserted through a severe and chronic pain enough by using other treatsmall cut in the skin and pushed through to the spinal ment options. The question of whether to go through disk. This path is used to get all of the surgical instruwith surgery is often difficult to answer, though. For ments to the disk. X-rays are used to help guide these surgery to be considered, imaging techniques and instruments to the right spot. The risks of this procethe symptoms must clearly show that a slipped disk is dure include bleeding, nerve damage and inflammacausing the pain. Before deciding to go ahead with the tion. procedure, it is important to carefully weigh the pros - Surgery on the center of the spinal disk: In and cons together with your doctor. Your individual these indirect procedures, the gel-like center of the situation will also be part of this discussion because spinal disk is removed to make the spinal disk itself it will also play a role in the success of the treatment. smaller, which will reduce pressure on the pinched The aim of surgery is to remove spinal disk tissue that nerve. All of these procedures involve inserting an inis affecting the pinched nerve. The idea is to give the strument into the spinal disk to reach the center. The nerve more space so the inflammation can subside center of the spinal disk can be removed using suc18
tion. This is called percutaneous nucleotomy. Or it is vaporized using laser beams (laser discectomy). This procedure may also have side effects, such as tissue damage caused by the heat. These operations are only considered if the outer layer of the spinal disk is still intact. These different surgical procedures have been studied in a number of trials and have in part been compared with one another. Most of the trials involved surgery on people who had pain for weeks despite receiving other treatment. One of the larger trials mostly included people with severe sciatica. The outcome: if someone is a suitable candidate for surgery, it can relieve pain and other symptoms such as limited mobility over the long term. The participants’ pain improved soon after surgery, whereas their mobility only improved a few weeks later. But there is no guarantee that surgery will make the symptoms go away – symptoms may continue or even get worse after an operation. Research shows that rehabilitation directly following slipped disk surgery (follow-up rehabilitation) can shorten recovery time and improve mobility. You can find out more about this in our research summary on rehabilitation after surgery on a slipped disk. Stay active and consider the treatment options Acute low back pain usually has no clear cause and goes away on its own after a few days. And even if a slipped disk is the root cause, your body will probably be able to deal with the problem on its own within six weeks. Most treatments will have a very small effect on the speed of recovery. Hot packs or massages might help you feel better. If you have severe pain, relaxing by getting into a position that reduces the strain on your back and taking anti-inflammatory drugs can help relieve symptoms over the short term. But most of the work is usually done by the body itself. If slipped disk symptoms persist for a longer time,
surgery may be an option to try to relieve the affected nerve. However, most experts believe that more operations for slipped disk are done in Germany than are actually necessary. If your doctor advises you to have surgery and you are not sure whether it is the right treatment for you, it may be a good idea to seek a second opinion. The most important thing is to stay as active as possible despite the pain and not to let it affects your daily routine too much. Exercise will not only keep your body in shape, it generally also has a positive effect on your mood. It is important to get enough exercise to stop back pain from becoming chronic. Physical activity has been scientifically proven to have a preventative effect – and it is probably the most important thing you can do to help yourself.
Health information is based on research in the international literature. 19
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