Question
I have a 19-yr-old son that injured his back while working in December.  He lifted too much weight (150 lbs of grout).  He's had conservative treatment consisting of physical therapy, stretching, pain medication, and anti-inflammatory meds. Since this is workers' comp, we've been trying to closely follow the doctor's advice. An MRI was conducted in February, and we were told then the results were not significant.  They have not wanted to refer him to a chiropractor or for any other treatment (however, they did refer him to an orthopedist who ordered the MRI and then said it was not significant.) Meanwhile, his symptoms have become worse, like sciatica, with pain and numbness running down his back side on the left and down his leg.  

He's now been allowed to see another industrial doctor after we complained.  Today she looked at the MRI report from Feb. and advised us that his symptoms are not due to his injury but as the report states: "L5-S1- There is a small focal central disc protrusion and probable mild to moderate bilateral facet hypertrophic change, the degree of facet degenerative change is more than is usually seen in a patient of this age (19).  There is mild left and minimal right neural foraminal narrowing at this level."   

This is difficult to believe because prior to his injury, he did not have any bad pain whatsoever.  

Any advice or help would greatly be appreciated.  We don't have a lot of money and if this matter cannot be through workers' comp., I'm not sure what we'll do.

Answer
Dear Pat,

You may want to print this information out.  

Here is the first problem...your son is being treated within the work comp system which is notorious for having poor quality physicians of all types, poor examinations, poor care, and deliberately negating a persons injury to reduce costs.  It is often the case that good physicians will not participate with workers comp programs due to the programs inadequacies in dealing with patients and reimbursement to the physician. I really doubt that the doctors your son has seen care about this case.  The fact that they would not refer you to a chiropractic physician is proof of their biases for treatment.  Furthermore, your son displays the classic signs of disk herniation/nerve root encroachment especially considering the pain distribution down the leg, and he is not getting any better.  

Concerning the MRI findings, the degeneration visualized should not be as significant as reported in his age group.  However, the fact that there is a small central disk protrusion with neuroforaminal encroachment is also significant.  We don't just randomly find disk protrusions on 19 year old men, especially with narrowing of the neuroforamen.  This is very abnormal for his age group.  

Now, here is another tidbit you might find interesting.  The mechanism of injury to create a disk bulge/tear is repetitive forward bending, made worse with twisting, which is further compounded by any lifting (even small weights). Now we have some issues to consider:

1.  It has been estimated that disc-bending activities were increased 300% and ligament stresses by 80% in the morning compared to the evening and there is an increased risk of injury in the morning when bending forward (Adams et al 1987) People should not undertake spinal exercise that require bending early in the morning which holds true for any occupational task that requires full spinal bending.

2.  Classic disk herniation appears to be associated with repeated flexion motion with only moderate loading required (Callaghan & McGill 2001).  Twisting moments place very large compressive loads on the spine because of the spinal musculature (McGill 1991).

3.  The ability of the spine to bear load is a function of the curvature of the spine.  A fully flexed spine is weaker than one that is moderately flexed (Adams et al 1994).  A fully flexed spine is 20-40% weaker than if it were in a neutral posture (Gunning et al 2001).

4.  Callaghan and McGill (2001) have been able to consistently produce disk herniations by mimicking the spine motion and load patterns seen in workers.  Specifically, only a very modest amount of spine compression needs to be required (only 800-1000 N or 177-200 lbs) with repeated spine flexion (forward bending).

5.  Cumulative exposure to unchanging work has been linked with intervertebral disk injury (Videman et al 1990)

6.  It is becoming clearer that repeated spine flexion-even in the absence of load-will lead to discogenic troubles.  (Mcgill 2002)

7.  Finally, during lifting, muscle and ligament forces required to support the posture and facilitate movement impose mammoth loads on the spine.  If a man is lifting a 59 lb object using a squat lift (almost no bending), the forces in the tissues that support the movement impose a compressive load on the spine of over 7000 N or 1568 Lbs.  It should be noted that 1568 lbs of compressive force begins to cause damage in weak spines, and this is just with one lift performed correctly.  Now factor in 150 lbs of grout lifted improperly with spine flexion and repetitive motion and you can see that disk injury can easily occur in a 19 year old male.  Even if lifted appropriately, the forces would approach 5000 lbs of compressive force.

So you can see that even with the few citations I have quoted above, that this injury can easily be attributed to the work injury your son has attained.  There are hundreds of research papers on this issue and the above is just a small touch of information on the subject.   

With the above in mind, it is also common for physical therapists to recommend repeated spine flexion and extension exercises in rehab to reduce back pain, which you probably already realize is incorrect.  Stabilization should be stressed, and flexion/extension exercises should be very limited.  This may be why the physical therapy was ineffective. Many commonly prescribed exercises result in so much spine compression that they will ensure that the patient remains symptomatic.  For example the traditional sit up imposes approximately 3300 N or 730 lbs of compression on the spine.  **The National Institute of Occupational Safety and Health set the limit for low back compression at 3300 N in 1981.  Repetitive loading above this level is not recommended yet sit-up are often performed in physical therapy for back pain sufferers**. Furthermore, McGill states that sit ups should not be performed at all by most people.

I suggest to you Pat that you fight to have your son treated by a chiropractic physician who specializes in sports injury or rehabilitation to stabilize his low back and prevent further damage.  Exercises that should be utilized are: side arm bars, bird dogs, and fast walking exercises with a full arm swing.  I would further suggest that you may wish to consult with an attorney to make sure that your son is represented in this matter.  It is obvious to me that the doctors are not looking out for his best interest.  Hope this helps.

Respectfully,
Dr. J. Shawn Leatherman
www.suncoasthealthcare.net