Author Archives Mark Croucher

The doctor’s diagnosis was what??

Posted by Mark Croucher
on February 15, 2016
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considering  surgeryI would like to preface this article review with my own observance.  Personally I’ve been impressed by the ability of many of my medical colleagues to assess and diagnose musculoskeletal issues.  On the other hand I’ve met some doctors that are outright terrible.  This is a problem in healthcare across the board.  It doesn’t matter if you’re talking about medical doctors, chiropractors, physical therapists etc.  One of the most common reasons patients go to the doctor in the world, is for back pain.  It accounts for one of the most prevalent reasons for disability in the United States.  Therefore, your doctor’s ability to diagnose these conditions is paramount for proper patient care.

A 2015 study in The Journal of Bone and Joint Surgery examined the competency of musculoskeletal medicine of medical students in the United Kingdom.

Two hundred and thirty students were recruited, of whom 210 were suitable for inclusion. Unfortunately, only 21% (forty-four students) passed the assessment.  When questioned, only 40% of participants considered themselves competent in musculoskeletal medicine.

Our findings suggest that medical schools may be currently failing to ensure that medical students have a basic competence in musculoskeletal medicine. Further investigation is warranted to fully assess the current training provided by U.K. medical schools in musculoskeletal medicine, and appropriate steps must be taken to improve the quantity and quality of training in musculoskeletal medicine in the United Kingdom.


J Bone Joint Surg Am. 2015 Apr 1;97(7):e36. doi: 10.2106/JBJS.N.00488.  The inadequacy of musculoskeletal knowledge in graduating medical students in the United Kingdom.   Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.

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Fear can make you hurt!

Posted by Mark Croucher
on February 14, 2016
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Feasurf shotr Avoidance – The fearavoidance model (or FA model) is a psychiatric model that describes how individuals develop chronic musculoskeletal pain as a result of avoidance behavior based on fear.

In our chiropractic practice, our focus is on the field of conservative spinal pain management and rehabilitation. We are mostly dealing with patients that have some type of chronic back or neck issue, often accompanied by neurological issues in their legs or arms (pain, numbness, weakness, tingling etc.).   A large percentage of our patients have had some type of spinal surgery that left them with a great deal of residual pain.  Other patients have been able to avoid surgery but continue to deal with chronically painful spinal issues.   Patients with these chronic issues start to behave differently.  They start to avoid anything and everything that their brain has learned might increase their symptoms.  This problem becomes a viscous cycle of negative feedback and actually worsens their painful problems.

A recent article in The Journal of Pain examined the neural components associated with pain anticipation and the changes in behavior that often occur.

This information could potentially help clinicians and patients to understand how anticipation of pain may contribute to patient pain and disability.

Our goals through treatment include:

  1. Identify the patient’s pain generator (area of injury).
  2. Through proper treatment, start to increase their abilities for normal movement.
  3. Get the patient to be able to face painful activities and learn that they can overcome.




Brain areas involved in anticipation of clinically-relevant pain in low back pain populations with high levels of pain behaviour.J Pain. 2016 Feb 1.



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Non-steroidal anti-inflammatory drugs for chronic low back pain.

Posted by Mark Croucher
on February 12, 2016
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Non-steroidal anti-inflammatory drugs for chronic low back pain.

Cochrane Database Syst Rev. 2016 Feb 10

Chronic back pain is an important health problem. Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used to treat people with low back pain, especially people with acute back pain. Short term NSAID use is also recommended for pain relief in people with chronic back pain. Two types of NSAIDs are available and used to treat back pain: non-selective NSAIDs and selective COX-2 NSAIDs.

In 2008, a Cochrane review identified a small but significant effect from NSAIDs compared to placebo in people with chronic back pain. This is an update of the Cochrane review published in 2008 and focuses on people with chronic low back pain.

Due to inclusion of Randomized Controlled Trials only, the relatively small sample sizes and relatively short follow-up in most included trials, we cannot make firm statements about the occurrence of adverse events or whether NSAIDs are safe for long-term use.

Cochrane Database Syst Rev. 2016 Feb 10


Another study in Spine 2003 Spine (Phila Pa 1976). 2003 Jul 15

Chronic spinal pain: a randomized clinical trial comparing medication, acupuncture, and spinal manipulation.


The consistency of the results provides, despite some discussed shortcomings of this study, evidence that in patients with chronic spinal pain, manipulation, if not contraindicated, results in greater short-term improvement than acupuncture or medication.

However, the data do not strongly support the use of only manipulation, only acupuncture, or only nonsteroidal antiinflammatory drugs for the treatment of chronic spinal pain. The results from this exploratory study need confirmation from future larger studies.


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Surgical versus non-surgical treatment for lumbar spinal stenosis

Posted by Mark Croucher
on February 12, 2016
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As we note, our interests at The Spine Center of Williamsburg lie in the influence chiropractic and conservative manual and physical interventions may have on spinal stenosis.  It tends to be the most common patient presentation we deal with.  Lumbar spinal stenosis (LSS) is a debilitating condition associated with degeneration of the spine as people age.  Patients present with a number of symptoms including; leg pain, back pain, leg weakness, numbness in the legs, difficulty standing and walking, relief with sitting and bending forward.

The referenced Cochrane Systematic Review below was done to evaluate the effectiveness of different types of surgery compared with different types of non-surgical interventions in adults with symptomatic LSS.   Primary outcomes included quality of life, disability, function and pain. Also, to consider complication rates and side effects, and to evaluate short-, intermediate- and long-term outcomes (six months, six months to two years, five years or longer).

To this point the interventions we use at our office include:

  1. Lumbar flexion distraction (manually delivered traction)
  2. Lumbar flexion exercises
  3. Lumbar flexion manipulation
  4. Vibratory assisted muscular activation
  5. Lower extremity strengthening exercise
  6. Recumbent bicycle training

These conservative treatment outcomes have not been thoroughly compared to surgical outcomes to date.  Further study is needed at this point.  The Cochrane review had this to say:


Authors’ conclusions

We have very little confidence to conclude whether surgical treatment or a conservative approach is better for lumbar spinal stenosis, and we can provide no new recommendations to guide clinical practice. However, it should be noted that the rate of side effects ranged from 10% to 24% in surgical cases, and no side effects were reported for any conservative treatment. No clear benefits were observed with surgery versus non-surgical treatment. These findings suggest that clinicians should be very careful in informing patients about possible treatment options, especially given that conservative treatment options have resulted in no reported side effects. High-quality research is needed to compare surgical versus conservative care for individuals with lumbar spinal stenosis.


The Cochrane Library - Trusted evidence. Informed decisions. Better health

About the Cochrane Library

The Cochrane Library (ISSN 1465-1858) is a collection of six databases that contain different types of high-quality, independent evidence to inform healthcare decision-making, and a seventh database that provides information about Cochrane groups.

About Cochrane Reviews

What is a systematic review?

A systematic review attempts to identify, appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria to answer a given research question. Researchers conducting systematic reviews use explicit methods aimed at minimizing bias, in order to produce more reliable findings that can be used to inform decision making.

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Calcium for Bone Health?

Posted by Mark Croucher
on February 12, 2016
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OsteoporosiP1020154 (1)s is a big concern for everyone (not just women) and most of us know someone who ultimately died of complications of a broken hip. Development of a rounded mid back (“dowager’s hump”) can be painful in itself and indirectly drives neck/upper back and shoulder pain. Medications for osteoporosis such as Fosamax and Boniva are not without problems such as fractures and other bone disease (ironically) after prolonged use.

For decades we’ve been advised that high calcium intake equals higher bone density. This translates to dairy intake and calcium supplements. Increasingly, however, noncalcium factors are seen as more important for bone support.

Low acid foods (vegetables, fruits and roots/tubers such as carrots, beets and radishes), omega 3 fatty acids and magnesium in the diet positively correlate with high bone density but dairy intake does not. Moreover, the 1,000 to 1,500 mg per day of calcium intake usually advised cannot be provided by diet alone and is simply not something the body is accustomed to. Supplementing calcium to this degree invariably unbalances the optimal 1 to 1 ratio of calcium to magnesium.

Even worse, there is evidence that supplementing as little as 800 mg of calcium per day increases the risk of age-related macular degeneration (an incurable form of blindness).

So what can you do to maintain bone density?

* Supplements: Magnesium (500 mg/day)

Vitamin D3 (1,000 to 5,000 IU/day)

Fish oil (1,500 to 2,500 mg EPA and DHA/day)

Note: don’t take fish oil if you’re on anticoagulant medication without discussing it with your prescribing physician.

* Food: Eat more alkaline food (vegetables, fruits and tubers) and

Less acid foods (grains, cheese and meat).

* Exercise: Weight bearing activities such as walking and strength

training. Try for 2.5 hours (150 minutes) per week.

* Lifestyle: Don’t smoke and drink alcohol in moderation.

From Problems with Calcium Supplementation D. Seaman DC, MS, DABCN. Dynamic Chiropractic vol. 33, no. 24.

Post from Dr. Dan Carlson

dan carlson

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Headache relief

Posted by Mark Croucher
on February 11, 2016
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A 2016 study in BMC Musculoskeletal Disorders compared the effects of manipulation to mobilization and exercise in individuals with a type of headache called cervicogenic headache (CH).


The results of the current study demonstrated that patients with CH who received cervical and thoracic manipulation experienced significantly greater reductions in headache intensity, disability, headache frequency, headache duration, and medication intake as compared to the group that received mobilization and exercise; furthermore, the effects were maintained at 3 months follow-up. Future studies should examine the effectiveness of different types and dosages of manipulation and include a long-term follow-up.


BMC Musculoskeletal Disorders is an open access, peer-reviewed journal that considers articles on all aspects of the prevention, diagnosis and management of musculoskeletal and associated disorders, as well as related molecular genetics, pathophysiology, and epidemiology.

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Chiropractor / Manual Therapy

Posted by Mark Croucher
on February 10, 2016
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Information from the text book Biomechanics of Back Pain addressed Manual therapy.

The term manual therapy is used to describe the primary treatments that chiropractors use.  The authors describe that manual therapies appear to have a neurological effect on pain and improve healing of damaged muscles, tendons and ligaments by stimulating blood supply and preventing adhesions.  Manual therapy may also be helpful in treating painful intervertebral discs (or sciatica due to disc herniation) and this type of problem is receiving more formal scientific attention.

The Biomechanics of Back Pain (considered as a comprehensive, evidence-based approach to the management and treatment of back pain).  By Michael Adams, Nikolai Bogduk, Kim Burton, Patricia Dolan

Another study from the British Medical Journal points to the superior effectiveness of manual therapy over other interventions.

“Manual therapy is more effective and less costly than physiotherapy or care by a general practitioner for treating neck pain. Patients undergoing manual therapy recovered more quickly than those undergoing the other interventions.”

Cost effectiveness of physiotherapy, manual therapy, and general practitioner care for neck pain: economic evaluation alongside a randomized controlled trial.  British Medical Journal 2003

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Peyton Manning Declares He Has At Least One More Surgery In Him

Posted by Mark Croucher
on February 8, 2016
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Satire from The Onion

SANTA CLARA, CA—Following his team’s 24-10 win in Super Bowl 50, Denver Broncos quarterback Peyton Manning ended weeks of speculation surrounding his future by announcing Sunday that he has at least one more surgery in him. “I’ve had a long run and been a part of a lot of pretty big surgeries, but I still think I’ve got one more major operation left in the tank,” said Manning, adding that he had deliberated for the past six months with friends, family, and medical specialists before deciding that he wasn’t ready to hang up his hospital gown for good. “Ultimately, I have to listen to my body, but I’ll keep going as long as I can still handle the anesthesia. I just can’t imagine myself never being under those bright lights in the operating room again. I’ll get on the gurney one more time and then ride off into the sunset.” Manning refused to comment, however, when asked whether he would undergo his next surgery in Denver or potentially at a medical center in Los Angeles.

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I’m scared for Peyton Manning

Posted by Mark Croucher
on February 8, 2016
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I really hope Peyton Manning retires.

He’s had 4 cervical spine (neck) surgeries including fusion of the vertebra after the discs were cut out. He has been left with some neurological damage including numbness and weakness in his arm and hand.  But that’s not the part that I am scared about.  In fact there is a chance that the numbness and weakness will improve.  He was quoted about this issue.

“I can’t feel anything in my fingertips,” Manning said Thursday. “It’s crazy. I’ve talked to a doctor recently who said, Don’t count on the feeling coming back. It was hard for me for about two years, because one doctor told me I could wake up any morning and it might come back. So you wake up every day thinking, Today’s the day! Then it’s not.”

I’m scared for him because of the current lack of natural flexibility in his neck due to the the fusion surgeries.  The middle and lower part of his neck is now RIGID with screws and plates holding the vertebra together.  From a mechanical standpoint this makes his neck more suceptible to what is called adjacent level disease (where the spinal levels above or below the fusion breakdown).  I have not been able to find any literature on “IF” fusion surgery makes the spine easier to break.  It makes one worry a bit though doesn’t it?

What happens to his neck if one of these massive men slam him to the ground on his head and rigid neck. Or if they happen to ram heads with him during an aggressive tackle.  Sure, anyone who plays professional football is accepting and inherent risk to life and limb but I believe his chance for neck fracture, in this particularly violent game, is elevated as a result of the altered rigid biomechanics of his neck.

Peyton, your legacy in sports is complete.  Spare your family from the fear that they must have each time you step on a football field.  I feel it so they must feel it ten fold.


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Do I have spinal degeneration?

Posted by Mark Croucher
on February 6, 2016
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considering  surgeryStudies have shown that patients without any pain have various evidence of spinal damage, degenerative changes and spinal joint arthritis.  Other studies have indicated that future spinal pain may be much more probable due to these types of spinal break down.



The statistics above are taken from:

Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations

American Journal of Neuroradiology


The mission of AJNR is to further knowledge in all aspects of neuroimaging, head and neck imaging, and spine imaging for neuroradiologists, radiologists, trainees, scientists, and associated professionals through print and/or electronic publication of quality peer-reviewed articles that lead to the highest standards in patient care, research, and education and to promote discussion of these and other issues through its electronic activities.


AJNR will continue to be internationally recognized as the primary source of information regarding all aspects of neuroimaging, including head and neck and spine imaging, for all professionals engaged in these and related fields. Continued optimization of delivery will enable it to and enhance patient care, research, therapy, training, and life-long learning.

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