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Cervical Disk Herniations: Common Questions

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DRX9000c Cervical Decompression

We have been providing natural solutions for cervical disk herniations in San Francisco for over 20 years now in the SF Financial District. We are located in the landmark Embarcadero Center One.

Last month, we discussed the topic of neck pain arising from cervical disk herniations. The focus of this month’s Health Update is common questions that arise from patients suffering from cervical disk derangement.

1. “What can I do to help myself for my herniated disk in my neck?” The mnemonic device “PRICE” stands for Protect, Rest, Ice Compress, and Elevate is a good tool to use in the acute stage of many musculoskeletal conditions.

  • Protect your health by NOT placing yourself in an environment that is likely to harm you, such as playing sports or doing heavy yard work. That is, think about what you do BEFORE you do it and if sharp, radiating pain occurs, STOP and assess the importance of what you are doing. Use the concept, “…don’t pick at your cut.” This means if you want the injury to heal, don’t keep irritating it!
  • Rest is similar. Limit your activities to those that can be done without increasing symptoms, especially radiating pain.
  • Ice – The use of ice reduces swelling/inflammation, which reduces pain and promotes healing. Alternate it every 15-20 minutes (on/off/on/off/on) several times a day. You can also use contrast therapy (Ice/heat/ice/heat/ice) at 10/5/10/5/10 minute intervals to “pump” out the swelling.
  • Compress – The use of a collar worn backwards, if it’s more comfortable that way, can literally “take the load off.” the neck and disks. There are even inflatable collars which are pumped up with air to traction the neck. Other forms of traction will be discussed further.
  • Elevate – The concept of raising the ankle to the height of the heart so swelling can drain out of the ankle is the classic example of “elevation.” In the neck, the traction concept may apply once again.

 

2. “I don’t want to have surgery if I can help it. What can you do as a chiropractor to help me?” This is one of our primary goals, and in fact, the goal of ALL health care providers, even surgeons! Chiropractic offers anti-inflammatory measures: ice, herbal anti-inflammatory agents (ginger, turmeric, bioflavonoid, curcumin, bromelain, Rosemary extract, Boswellia Extract, and more), digestive enzymes taken between meals, muscle relaxant nutrients (valerian root, vitamin D, a B complex, chamomile, magnesium, and others) as well as other non-pharmaceutical options. Treatments consist of manual manipulation, mobilization, traction (for home and office), modalities such as deep tissue laser therapy and low-level laser, electrical stimulation, magnetic field, ultrasound, and others. We also offer nonsurgical cervical decompression with the DRX9000c. Most important is having a “coach” guide you through the stages of healing by first addressing the acute inflammatory stage (first 72 hrs), the proliferative or reparative phase (up to 6-8 weeks), followed by the remodeling phase (8 weeks to 1 or 2 years) and finally, the contraction phase (lifetime – includes the natural shortening of scar tissue). If manual traction reduces neck and arm pain, the use of home traction is very effective. Options include sitting over-the-door traction, laying down versions, and mobile traction collars (discussed previously). Exercises to stretch and strengthen the neck are also very important in reducing neck pain as well as preventing recurrences. If in spite of all the best efforts of this non-surgical care approach should ongoing neurological loss and relentless symptoms continue, we will coordinate care with physiatrists for possible injection therapy and pharmaceuticals, with neurology for further testing (such as EMG/NCV – a nerve test), and/or neuro- or orthopedic surgery – THE LAST RESORT!

            We realize that you have a choice in where you choose your healthcare services.  If you, a friend or family member requires care for neck pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.

To schedule a consultation for cervical disk herniation treatment in San Francisco please call 415-392-2225. Mention this blog post for a complimentary consultation.

Scott Calzaretta

Chiro-Medical Group is an innovative collaboration of health care professionals who work together as a team to promote optimal health. Our group includes experts in the fields of medicine, chiropractic, physical therapy, massage, nutrition, and personal athletic training.

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Spinal Decompression or Chiropractic for a Disc Herniation?

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Spinal Decompression Therapy with DRX9000

We have been providing chiropractic in San Francisco for over 20 years now. About 8 years ago we began to incorporate spinal decompression with the DRX9000 into the mix.

In general, we always want to rule out chiropractic as a first choice for herniated discs in the neck or low back. Spinal decompression is more expensive and time consuming and is not covered by insurance.  Actually, most insurance will cover re-exams, exercises, ice, muscle stimulation, and some of the ancillary services we provide to decompression patients.

If a patient presents with a new condition, even though it appears to be a herniated disc (it’s not hard to tell)…we still want to try conservative chiropractic care first if the patient can tolerate it…and most can because we start out very gentle and easy.

On the other hand…if a patient comes to us and has already tried chiropractic without much success, or we treat them ourselves without any change, say after a few weeks, then we consider decompression therapy and will usually order an MRI.

A few weeks ago we had a 28 year old male present with severe back and leg pain with no apparent cause. He was listing to one side (antalgia) which is common with a lumbar disc herniation, and had all the positive disc findings…another-words chances are he has a herniated disc…we would need MRI to confirm.

Our game plan was to treat with conservative chiropractic for a few weeks and see if we could stabilize him and get him back on track. He really wanted to avoid an MRI and the  time and expense of spinal decompression.

The treatment started out slow with not much change…then after 4 chiropractic adjustments he started to come around, sleep better, stand straighter, feel better, and have hope that chiropractic can help.

As it stands he had to go on a work trip and will be back at the end of the week. This is not ideal so we will see.

I guess the point is this…We always want to try the more conservative, less expensive chiropractic adjustments first when it comes to treating bulging and herniated cervical and lumbar discs. But we have a Plan B if we need it, Nonsurgical spinal decompression with the DRX9000 or DRX9000c (cervical decompression system).

To find out if you are a candidate for spinal decompression in San Francisco, call 415-392-2225. Mention this blog post for a complimentary consultation.

Scott Calzaretta

Chiro-Medical Group is an innovative collaboration of health care professionals who work together as a team to promote optimal health. Our group includes experts in the fields of medicine, chiropractic, physical therapy, massage, nutrition, and personal athletic training.

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Low Back Pain and Obesity

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Normal Body Weight = Decreased Low Back Pain

We have been providing treatment for low back pain in San Francisco for over 20 years now. One of our primary goals is to always try to help our patient’s maintain a normal body weight. Losing weight can dramatically reduce Low back pain (LBP). For the next 2 months, we will look at easy ways to lose weight without the need for fancy, hard to follow diets. As the saying goes, this is a “no-brainer.”

  1. Time you meals. Set a timer for 20 minutes and “pace yourself” so that you eat slower. This is one of the most effective ways to reduce weight without a complicated diet plan. Make each bite “count” and enjoy the food’s flavor! This tricks your brain into thinking you’re more full while wolfing down your food in a hurry blocks those brain signals, resulting in over-eating.
  2. Sleep an extra hour. This can result in a drop of 14 pounds a year according to University of Michigan research.
  3. Serve three vegetables and/or fruit vs. one in your evening meal. You can eat more and STILL reduce weight!
  4. Add a broth-based soup to your day. It fills you up without adding calories. Avoid creamy soups as they can be high in fat and calories.
  5. Eat more whole grains. Add brown rice, barley, oats, buckwheat and/or whole wheat when consuming waffles, pizza crust, English muffins, and pasta. If you are gluten sensitive, look for alternatives like quinoa.
  6. Visualize your favorite “skinny clothes.” Think about, or literally take out, a favorite dress or pair of pants that you no longer fit into and use it as a target or goal to wear them again.
  7. Skip the bacon! If you avoid that 2 strips of bacon at breakfast or on your sandwich at lunch, you’ll save about 100 calories / day, about 10 pounds per year! Instead add tomato slices, banana peppers, roasted red bell peppers, grainy mustard, or a light spread of herbed goat cheese.
  8. Pizza perfect! Choose a veggie topping vs. meat and shave 100 calories from your meal. Consider going light on the cheese, use reduced fat cheese and choose a thin, bread-like crust made with olive oil.
  9. Drink “smart!” Trade that soda in for water or zero-calorie seltzer and you’ll avoid about 10 teaspoons of sugar! Add a lemon, mint or frozen strawberries for a much more satisfying beverage.

            We realize you have a choice in who you choose to provide your healthcare services.  If you, a friend or family member requires care for low back pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.

To schedule an appointment for low back pain treatment in San Francisco call 415-392-2225. 

Scott Calzaretta

Chiro-Medical Group is an innovative collaboration of health care professionals who work together as a team to promote optimal health. Our group includes experts in the fields of medicine, chiropractic, physical therapy, massage, nutrition, and personal athletic training.

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Low Back Pain: What’s the best treatment?

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Low Back Pain

Low back pain (LBP) has been a challenge to treat for centuries and evidence exists that back pain has been a concern since the origins of man. Chiropractic offers one of the most patient satisfying and fastest treatment approaches available. But, when you go to a chiropractor, there seems to be a lot of different approaches utilized from doctor to doctor. Some use only their hands. Some, like our San Francisco Chiropractic team, use spinal decompression and chiropractic, as well as deep tissue laser, Active Release Technique (ART), and exercises. Is there any evidence that suggests one approach is favored over another? How are the patient’s goals addressed?

            Let’s look at what chiropractors actually do. Sure, we manipulate the spine and other joints in the upper and lower limbs using a variety of techniques, which seems to be the “brand” of chiropractic. This is good as joint manipulation has consistently been reported to be safe, effective, and with few side effects. Since this is the “staple” of chiropractic, it’s safe to say that regardless of our preferred or chosen technique, obtaining a good result is highly likely.

            But, chiropractic includes SO MUCH MORE than just joint manipulation! For example, we focus on the whole person, not just their isolated issue or complaint. Using low back pain and sciatica as our example, a “typical” evaluation includes a detailed history of the patient’s general health, past history, illness history, family history, personal habits including sleep quality, exercise habits, dietary issues, quality of life measurements and a review of systems. By gathering this information, we can identify areas that may be directly related to low back pain care, indirectly related, or possibly not related at all, but interferes with the person’s quality of life which, in turn, increases LBP. It’s really difficult to separate our low back from the rest of our body.

            For example, if a person has plantar fascitis, a heel spur, an ingrown toe nail, diabetic neuropathy in their feet, pes planus or flat feet, an unstable ankle from multiple sprains, knee or hip problems, the gait pattern or, the way a person walks will be affected and the “domino effect” can trickle up to change the low back/pelvic function — resulting in low back pain! Proper management must address all of the issues that are affecting the patient’s gait if long-term success in low back pain management is expected, rather that just putting a “band aid” on the problem.

            Let’s talk about what treatment goals we like to address when we treat our low back pain patient population. The most obvious first goal is pain cessation or getting rid of pain, especially if there is sciatica! Since this is what usually drives the patient into our office, patient satisfaction with the care received will not be significant unless the pain is managed. This is achieved through advice, reassurance and training. We often recommend ice (vs. heat) aimed at reducing inflammation, activity modification (teaching proper bending, lifting, pulling, and pushing techniques) and gentle stretching exercises when LBP is present in this acute stage.

            Once the pain becomes more manageable and activities become less limited, the second goal is structural restoration. This usually includes managing the flat foot possibly with foot orthotics, a short leg with a heel lift, sole lift or combination, an unstable ankle, knee or hip with exercise often emphasizing balance challenge exercises, and sometimes an orthotic that can be as simple as an elastic wrap to a more elaborate brace. This goal also includes “functional restoration” or transitioning the patient back into real life activities they may be afraid to try such as work, golf, gardening, walking or running, etc.

            The third goal is prevention oriented. This may include nutrition (including vitamin/mineral recommendations), weight management (though this is also part of the 2nd goal), exercises (aerobic, stabilization, balance, stretch), and stress management (yoga, lifestyle coaching, etc.). We treat ALL of you, not just your parts!

            We realize you have a choice in who you choose to provide your health-care services.  If you, a friend or family member requires care for low back pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.

To schedule an appointment for low back pain treatment in San Francisco, call 415-392-2225. Mention this blog post for a complimentary consultation.

Scott Calzaretta

Chiro-Medical Group is an innovative collaboration of health care professionals who work together as a team to promote optimal health. Our group includes experts in the fields of medicine, chiropractic, physical therapy, massage, nutrition, and personal athletic training.

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Neck Pain: Manipulation vs. Mobilization – What’s Better?

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Neck and Upper Back Manipulation

Does mobilization (MOB) get less, the same, or better results when compared to spinal manipulative therapy (SMT)? To answer this question, let’s first discuss the difference between the two treatment approaches.

             Mobilization (MOB) of the spine can be “technically” defined as a “low velocity, low amplitude” force applied to the tissues of the cervical spine (or any joint of the body, but we’ll focus on the cervical region). This means a slow, rhythmic movement is applied to a joint using various methods such as figure 8, side to side, front to back and /or combinations of any of these movements. In the neck, gentle to firm manual traction or pulling, when applied to the cervical spine, stretches the joint and disk spaces and can be included during MOB. Some consider nonsurgical spinal decompression to be a form of Mobilization. In my opinion decompression therapy is it’s own category.

             Spinal Manipulative Therapy (SMT) can be defined as a “high velocity, low amplitude” type of force applied to joint which is often accompanied by a audible release or “crack,” which is the release of gas (nitrogen, oxygen, and carbon dioxide). Some joints “cavitate” or “crack” while others are less likely to release the gas. This is what a chiropractic adjustment does and is what we do at our San Francisco Chiropractic Clinic.

Studies that date back to the 1940s report an immediate improvement in a joint’s range of motion occurs when the joint cavitates. Many people instinctively stretch their own neck to the point of gas release, which typically, “…feels good.” This can become a habit and usually is not a big problem. However, in some cases, it can lead to joint hypermobility and ligament laxity.  As a rule, if only a gentle stretch is required to produce the cavitation/crack, it’s typically “safe” verses the person who uses higher levels of force by grabbing their own head and twisting it beyond the normal tissue stretch boundaries. The later is more likely to result in damage to the ligaments (tissue that strongly holds bone to bone) and therefore, should be avoided.  Since SMT is usually applied in a very specific location (where the joint is fixated or “stuck”, or, partially displaced), it’s obviously BEST to utilize chiropractic,  as we chiropractors do this many times a day (for years or even decades) and we know where to apply it and can judge the amount of force to utilize, especially the neck where there are many delicate structures.

            Back to the question: Which is better, MOB or SMT? Or, are they equals in the quest of rid of neck pain? A recent study of over 100 patients with “mechanical neck pain” (strain/sprain)  showed that those who received SMT had a significantly better response than the MOB group as measured by a pain scale, a disability scale and 2 tests that measure function! So, the next time you ask the question, “….do you have to crack my neck?,” the answer should be “yes, if you want to achieve the quickest response.” However, if there is sharp pain during the “set-up” of the manipulation or adjustment, modifications in the technique are appropriate or, a different method should be considered.

            We realize that you have a choice in where you choose your health-care services.  If you, a friend or family member requires care for neck pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.

Special Note: When SMT fails to deliver results, spinal decompression therapy should be considered as a treatment option for back and neck pain secondary to herniated and bulging discs.

To schedule an appointment with one of our Back and Neck Pain Experts in San Francisco, call 415-392-2225.

Scott Calzaretta

Chiro-Medical Group is an innovative collaboration of health care professionals who work together as a team to promote optimal health. Our group includes experts in the fields of medicine, chiropractic, physical therapy, massage, nutrition, and personal athletic training.

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Low Back Pain and Spinal Manipulation: How Does it Work?

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Spinal Adjustment

For many years, Chiropractic has been at the forefront of treating low back pain (LBP) with both greater patient satisfaction and less lost time at work when compared to other non-surgical treatment approaches. There have been many explanations as to why chiropractic manipulation therapy (CMT) works but many of these studies include other treatment modalities or methods and the benefits are ,therefore, not clearly derived only from CMT.  A recent study has tried to clear this up and the results are very interesting!

This study included two chiropractors and two a physical therapists (PT) from Canada and the US. What is unique about this study is that they measured clinical or symptomatic improvement by tracking improvement in activity tolerance using a standard questionnaire commonly used by chiropractors and PTs all over the world, as well as changes in the spinal stiffness using a valid/reliable instrument before and after CMT was utilized. The importance of these findings is that only CMT was utilized and hence, other forms of treatment commonly utilized by chiropractors did not cloud the findings. There were 48 patients included in the study and the initial 2 treatments were administered 3-4 days apart, followed by an assessment 3-4 days after the 2nd treatment. Assessments were also performed before and after each treatment. The assessments included use of the questionnaire and a stiffness measurement using the special instrument. Also, “recruitment of the lumbar multifidus muscle” (a muscle in the low back that helps stabilize the trunk or core) was measured by ultrasound. After each treatment, significant improvement was found in the overall pain level and in reduced spinal stiffness (which remained improved 3-4 days after the last/second treatment).

The study conclusions revealed less pain, more activity tolerance and less spinal stiffness after the administration of the 2 treatments. The greatest clinical improvement was found in those who had the most dramatic reduction in stiffness after each treatment. They found that the level of muscle recruitment was directly related to the degree of spinal stiffness.  They also found that patients who received thrust manipulation (CMT) had immediate improvements with reduced pain, stiffness and improved muscle recruitment measurements. However, this same effect was NOT obtained when non-thrust mobilization techniques were used. This means many non-thrust manual techniques such as mobilization, massage, and other soft tissue release methods do not create the immediate benefits that were produced by thrust manipulation.

With this new information, we are now able to explain with confidence to patients the reasons why they typically feel better after the spinal adjustment. The patient can then appreciate receiving an answer that makes clear sense and has been “proven.” It’s important to realize that the “bonus” of receiving chiropractic care for low back pain includes not only just pain reduction, but more importantly, improvement in tolerating activities such as vacuuming, washing dishes, golfing, walking and of course, working.

            We realize you have a choice in who you choose to provide your health-care services.  If you, a friend or family member requires care for low back pain, we sincerely appreciate the trust and confidence shown by choosing our services and look forward in serving you and your family presently and, in the future.

To schedule an appointment with one of our San Francisco Chiropractors call 415-392-2225. Mention this blog post for a complimentary consultation.

Scott Calzaretta

Chiro-Medical Group is an innovative collaboration of health care professionals who work together as a team to promote optimal health. Our group includes experts in the fields of medicine, chiropractic, physical therapy, massage, nutrition, and personal athletic training.

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Herniated Disc? What happens if you do nothing?

We have been providing treatment for herniated discs in San Francisco for about 20 years now. During this time we have learned much. About 7 years ago we added nonsurgical spinal decompression to our treatment protocols. A while later deep tissue laser.

herniated disc treatment san francisco
Herniated Disc Treatment

So what happens if you are diagnosed with a herniated disc and you take no action?

It just depends.

Chances are if you have been diagnosed with a herniated disc you had an MRI…which is the “gold standard” diagnostic tool when it comes to confirming the presence of disc herniations or disc bulges.

And if you had an MRI you are most likely symptomatic…meaning you have symptoms such as sciatica from a lumbar disc herniation, or radiating arm pain from a cervical disc herniation.

So now your medical doctor tells you YES…you do in fact have a disc herniation in your lumbar spine at L5 and he wants to do surgery to remove it. WOW…what now?

Well…if it were me I certainly would not agree to low back surgery right off the bat. I would explore nonsurgical options such as nonsurgical spinal decompression with the DRX9000.

I would also consider major lifestyle modifications such as weight loss, giving up all bad habits such as smoking, drugs, drinking (if excessive) and anything else I was doing that was bad. I would seriously consider adopting a plant based diet such as the McDougall Program to reduce inflammation and help the disc to heal. I would go 100% clean and try to work it that way.

But that’s me…and most are not willing to do this. Plus, it might not work for you. A certain percentage of cervical and lumbar disc herniations simply are stuck on nerves in a way that requires that they be physically removed and lifestyle changes will do nothing for them other than provide a healthier context improved over-all health.

If you do nothing you just keep getting worse and the herniated disc will become more difficult to treat the longer you let it go. And your life will become even more miserable.

drx9000 in san francisco
Lumbar Decompression For Chronic Back Pain

Or, you can make all the lifestyle changes (or not) and try nonsurgical spinal decompression on a machine like the DRX9000. The DRX9000 is designed and built to actually isolate on a herniated disc and physically remove it from the spinal nerve it is irritating. It does this by creating a negative pressure, elongating the spine, enlarging the disc space, re-positioning the disc back where it belongs. YES it really does do this.

So sure…you can jump right into neck or back surgery and risk all kinds of bad stuff. You can do nothing and risk the problem getting worse and becoming more difficult to treat. Or you can try spinal decompression therapy and see if you can get your life back…naturally.

Sure, there’s a chance disc decompression will not help you…but success rates are high…so it’s a chance worth taking 🙂

To schedule a complimentary consultation to see if you are a candidate for spinal decompression with the DRX9000…contact our San Francisco Spinal Decompression Center at 415-392-2225.

Scott Calzaretta

Chiro-Medical Group is an innovative collaboration of health care professionals who work together as a team to promote optimal health. Our group includes experts in the fields of medicine, chiropractic, physical therapy, massage, nutrition, and personal athletic training.

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Best Treatment for Sciatica from a Pinched Nerve

Sciatica means pain down the leg. The Sciatic Nerve is the largest nerve in the body. It can be as large as the diameter of a quarter at it’s largest point in some people. It is formed from branches of nerve roots as they exit the lumbar spine (low back). The sciatic nerve then travels down through a muscle in the buttocks called the Piriformis Muscle, then all the way down the back of the leg to the feet.

pinched nerve treatment san francisco
Pinched Lumbar Nerve Root of Sciatic Nerve

All nerves are very delicate and sensitive to pressure. In fact, all it takes is the weight of a pencil erasure on a nerve to alter it’s signal by up to 60% and cause pain and dysfunction. Because the bones of the spine are movable, and the nerve roots exit from in between them, the nerve roots may be pinched or irritated from bulging discs or herniated discs that encroach on the environment of the nerve as it passes through the nerve channel in between the vertebrae. This is called a pinched nerve.

There are many terms used to describe the cause of a pinched nerve in the lumbar spine from a herniated disc. The most common terms are ruptured disc, torn disc, slipped disc, herniated disk, bulging disk, prolapsed disc, etc.

The bottom line is that the spinal disc is injured and the jelly like center (nucleus) of the disc is bulging out or has broke free of the disc and is pinching the lumbar nerve root.

Bulging discs and herniated discs are the primary cause of sciatica. The sciatic nerve can also be pinched as it passes through the piriformis muscle, if the muscle is in spasm…which is common with long haul truck drivers or men that wear thick wallets while they sit. This is called Piriformis Syndrome.

Pinched Sciatic Nerve in Piriformis Muscle

Sciatica can be mild, or it can be severe and debilitating. It can be acute or chronic (lasts for more than 3 months). Sciatica can also be used to describe ongoing abnormal sensations in the legs and throbbing.

So what’s the best treatment for sciatica from a pinched nerve?

The medical approach will usually be muscle relaxers, cortisone injections, pain pills, and maybe physical therapy. Depending on the age of the patient and over-all condition of the spine, surgical fusion may be recommended, or a micro-surgery like a discectomy (remove herniated disc fragments off nerve).

A chiropractor will want to adjust the spine into a more normal alignment with the idea that the disc will naturally want to be where it is supposed to be…which is not on the sciatic nerve or nerve roots. Chiropractors will often use soft tissue therapies such as massage and Active Release Technique as well as exercises and laser therapy.

Acupuncture can also help reduce the inflammation and pain associated with disc bulges, disc herniations, and piriformis syndrome.

Nonsurgical spinal decompression should also be considered as a treatment for sciatica due to a pinched nerve. Spinal disc decompression to the lumbar spine is done on a spinal decompression machine such as the DRX9000. The DRX9000 lumbar decompression system is designed and built to treat herniated and bulging discs naturally.

New York City spinal decompression doctor Steven Shoshany uses spinal decompression in conjunction with physical therapy, acupuncture, and physical medicine to achieve favorable outcomes for severe, chronic low back pain and sciatica.

Spinal decompression is a tool that can be combined with many other therapies and modalities to treat sciatica and low back pain.

If you would like me to help you find a spinal decompression doctor…simply send an email to ebendavis@yahoo.com. You can also check our list of recommended chiropractors. Most of them offer spinal decompression services.

To schedule an appointment at our San Francisco Spinal Decompression Center call 415-392-2225 and ask for a complimentary consultation.


Scott Calzaretta

Chiro-Medical Group is an innovative collaboration of health care professionals who work together as a team to promote optimal health. Our group includes experts in the fields of medicine, chiropractic, physical therapy, massage, nutrition, and personal athletic training.

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