MONTHLY HEALTH UPDATE
Is Your Foot Causing Your Knee Pain?
Chad Abramson, D.C.
Whole Body Health
Pregnancy and Low Back Pain – Part 2
Back pain can become both more frequent and more intense as a pregnancy enters
into the second and (especially) the third trimester. This is because the biomechanical
changes that accompany pregnancy occur too fast for the body to properly adapt.
Besides the usual suggestions of bed rest, taking frequent breaks, using cold packs,
and the like, there are many benefits derived from manual therapies such as manipulation,
mobilization, massage, and exercise.
Chiropractors frequently offer these services, and one or a combination of these therapies can result in significant relief of back pain during pregnancy. One study reported that 94% of pregnant women receiving chiropractic treatment demonstrated clinically important improvement with substantial relief for several days following their initial treatment, with no adverse effects.
In a survey of 950 pregnant women and 87 medical providers, 31% responded that effective alternative therapies used during pregnancy included chiropractic care, massage, and yoga exercises. In a review of 400 pregnant female medical charts after delivery, 84% reported relief of back pain during the pregnancy with chiropractic care.
Studies have also shown that women with back pain during pregnancy have an elevated risk for a longer labor and delivery. Additionally, first-time pregnant women (primigravida) who received chiropractic care throughout their pregnancy averaged a 25% shorter labor time, while women who were pregnant after already having a child (multiparous) reported a 31% average shorter labor time.
Co-management and referrals between medical providers and chiropractors are becoming more common due to the growing amount of evidence published regarding the benefits of spinal manipulation during pregnancy.
Chronic Whiplash Injuries and Pain Thresholds
Researchers have observed a phenomenon called “central sensitization” (CS) that is common
in patients who have long-term, chronic pain following trauma such as whiplash. With CS, the
patient's ability to feel pain is abnormally high or hypersensitive, so when pain from pressure,
temperature, electrical, or other sources is applied to the skin, they feel it sooner and more intensely
than individuals without CS.
Why is this so important? Well, if we can find a way to raise the pain threshold in patients with CS, then this could reduce the intensity and frequency of their sometimes intense and debilitating chronic pain.
Researchers have found that pain thresholds improve after an anesthetic agent is injected into myofascial trigger points (MTrP)—those tight, sore “knots” commonly found in muscles after injuries such as whiplash trauma. It has been proposed that these MTrP may act as “thermostats” controlling the manner in which the brain perceives and relays pain.
To test this theory, a 2017 double-blind study randomly assigned chronic pain whiplash patients to either a group receiving the “real” anesthetic agent or a “sham” or fake injection of the MTrP. The researchers measured pain (on a 0-10 scale), pressure perception, grip strength, and the range of motion (ROM) of the jaw in subjects from both groups before and after each intervention. As postulated, only the group receiving the “real” anesthetic agent had improved pressure pain tolerance in addition to increased jaw ROM. Unexpectedly, both groups experienced similar improvements when rating their pain on a 0-10 scale. This study concluded that the pain threshold associated with CS can be modulated by injecting myofascial trigger points (with or without an anesthetic agent), although only the anesthetized group had objective improvement (jaw ROM and pressure sensitivity improvement). Interestingly, the treatment of painful trigger points has LONG been a common form of care utilized by chiropractic, known as trigger point therapy or TPT. Myofascial release is another soft-tissue technique commonly utilized over MTrP by chiropractors. This study may help explain why so many patients benefit from chiropractic care following whiplash trauma as well as other injuries. The added benefits from spinal manipulation and modality use over trigger points are two additional ways chiropractic care can benefit those suffering from both acute and chronic pain associated with whiplash trauma.
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome Exercises
There are nine tendons that pass through the carpal tunnel at the wrist that connect the forearm
muscles to the palm-side of the fingers. These tendons are encased in sheaths, and friction and heat can
build-up inside these sheaths, leading to swelling, pressure, and pain (especially during fast, repetitive
tasks). As the swelling increases and pressure builds up inside the tight space of the tunnel, the median
nerve is pushed into the transverse carpal ligament, which serves as the floor of the tunnel, resulting in the
symptoms we commonly associate with CTS. Stretching helps reduce this tightness and friction.
The stretching exercises listed below can BOTH help CTS as well as prevent it from occurring or re-occurring. As a warm-up:
- Rotate the wrist in multiple directions—up, down, side-to- side, and figure 8s.
- Spread your fingers as wide as you can and pull the fingers back using your other hand (or a wall) keeping the elbow straight.
- Repeat step two, but this time, stretch the thumb back.
Repeat these steps five to ten times—enough to feel the forearms and hands loosen up.
The Prayer: Place your palms completely together like you are praying (keep the heels of the
hands together) next to your chest and slowly lower the hands toward the floor while keeping the hands
close to your body. Hold for 15-20 seconds.
Forearm Flexors: Arm straight, palm against the wall, fingers point downward, reach across and gently pull the thumb back. Hold for 15-20 seconds.
Forearm Extensors: Arm straight, back of the hand against the wall, fingers pointing downward. Hold for 15-20 seconds.
Repeat the above exercises three to four times and focus on feeling the muscles “release.” Try to do this three to five times a day, ESPECIALLY during the busy work day to “break-up” the monotony of fast, repetitive work tasks that can increase heat and friction in the sheathes surrounding the tendons that pass through your wrist.
Your doctor of chiropractic may recommend ice cupping over the wrist/s (palm side) and using a night splint on the affected wrist/s, in addition to exercises (like those above) and job modifications aimed at reducing CTS risk. Treatment may also include the use of manual therapies applied to the forearm, wrist, and hand, as well as the elbow, shoulder, and neck as these areas are frequently involved and must also be addressed to optimize the patient's outcome.
Shoulder pain can arise from a multitude of places—from joints, muscles, tendons, and bursa in
and around the shoulder region as well as from more distant locations like the neck, upper back, or even
referred pain from the gall bladder. The onset of shoulder pain is highly variable as it can arise without an
obvious cause or be related to a specific mechanism of injury such as a work or sports injury. Shoulder
pain can also occur as a result of repetitive trauma over time, such as a job requiring overhead reaching.
Neurological injuries such as stroke or a pinched nerve in the neck can cause shoulder pain as well.
Experts estimate that as much as half of the population experiences shoulder pain each year, though many
people often decide to “just live with it” and therefore, don't seek treatment. However, shoulder and neck
disorders do account for 18% of disability payments for MSK pain.
These following factors contribute to shoulder pain, either alone or in combination with each other:
Inflammatory conditions: Tendonitis, bursitis (the bursa are the fluid-filled sacs that lubricate
the surrounding tissues), osteoarthritis (the “wearing out” kind), and rheumatoid arthritis (the
autoimmune kind). Inflammatory conditions are a common cause of shoulder impingement (see
Excessive Motion: Instability can arise from tearing of the joint capsule, tendons, and/or ligaments that become lax after healing. The terms “strain” and “sprain” refer to tears of muscles and/or tendons (strains) vs. ligaments (sprains). Trauma typically results in instability in one direction vs. congenital (or “born with”) problems where instability can be multi-directional. This can result in a subluxation and/or a dislocation of the shoulder.
Limited Motion: This occurs when the joint capsule and ligaments are tight and restrict freedom of movement. This can happen after prolonged immobilization (use of a sling) and can result in impingement and/or “frozen shoulder” (adhesive capsulitis).
Muscle Weakness/Imbalance: The muscles in front, on top, behind, and those that connect from below must be in proper balance for the ball and socket joint of the shoulder to function properly.
Weakness in any of these muscles can alter the normal balance and result in shoulder pain due to poor, inefficient shoulder motion. A common example of this is forward head posture with shoulder protraction (forward, rounded shoulders) that many of us “suffer” from as a result of using electronics (smartphones, computers, television). Overtraining of any of these muscles (like the chest muscles), stroke, or pinched nerves can also alter muscle balance.
Impingement is a common cause of shoulder pain that arises from swelling or inflammation from the tendons and/or bursae. Here, the ability to raise the arm is limited. Chiropractors are trained to diagnose and treat shoulder conditions using the standard approaches like mobilization, exercise, ice, job modifications, and anti-inflammatory measures (modalities and nutritional approaches), as well as those unique to chiropractic such as shoulder joint manipulation, which can reduce impingement.
Neck Pain / Headaches
Chiropractic Care and Migraine Headaches
Migraines affect approximately 15% of the general population and are usually managed by
medication. However, this traditional treatment approach is not well tolerated by some migraine
sufferers due to side effects. Additionally, some people prefer to avoid the risks associated with
taking some medications over the long term.
A systematic literature review of randomized controlled trials (RCTs) involving the use of manual therapies to treat migraines found that chiropractic spinal manipulative therapy (SMT) is equally as effective as the medications propranolol and topiramate in the management of such headaches.
One case report featured the successful outcome of a 24-year- old pregnant female who had a history of migraine headaches starting at age twelve. She had previously tried other forms of care including osteopathy, physical therapy, massage therapy, and medication including a non-steroidal anti-inflammatory with codeine. Due to her pregnancy, she turned to chiropractic care in hopes of achieving relief without the use of medications. The application of spinal manipulative therapy along with other manual therapies led to a satisfying outcome which allowed her to cease using her medication.
Another case study featured a 72-year- old woman with a 60-year history of migraine headaches that included nausea, vomiting, photophobia (light sensitivity), and phonophobia (noise sensitivity). Prior to treatment, the patient averaged one to two migraines per week, which lasted one to three days in duration. Following a course of chiropractic care, her headaches resolved completely, which eliminated the need for any migraine medication. A follow-up seven years later confirmed her continued migraine-free status.
In a case involving a 49-year- old female patient suffering from migraine headaches following a car accident, a twelve-week course of chiropractic care utilizing SMT along with both active and other passive therapies led to significant improvements in the patient's migraine-related disability and pain.
In another case, a 17-year- old boy fell on his head while pole vaulting and began to experience bipolar disorder symptoms, seizures, sleeping problems, and migraine headaches. After failing to respond to various treatment approaches from numerous physicians, he sought treatment from a doctor of chiropractic at age 23. After four months of chiropractic care, his migraine frequency dropped from three times a week to twice a month. He reported a full recovery after seven months of care, which was sustained at an 18-month follow-up.
Whole Body Health
Women with Back Pain... The Silent Majority? Part 1
Because humans are bipeds—that is, two-legged animals—our spines tend to experience
greater loads than those our four-legged friends. This leads to men and women experiencing
degenerative conditions such as osteoarthritis much earlier in life compared with lions, tigers, and
bears (and your dog or cat). Also, the majority of us (about 90%) have one leg that's shorter than the
other (average 5.2mm or ¼ inch), which can tilt the pelvis downward on the side with the shorter leg,
which increases the risk for both back pain and neck pain. Fortunately, this can be rectified with a
heel lift in the shoe. However, women also face unique anatomical, physiological, and social
challenges when it comes to back pain…
Females have a wider pelvis, which aids in childbearing. This results in a greater Q-angle or “knock-knee” measurement in females than males (the “normal” angles are <22 degrees and <18 degrees, respectively). The greater the Q-angle, the less stable the pelvis, as it’s similar to folding the legs of a card table inward, which makes the table unsteady.
Another obvious anatomical difference includes breast size (weight and mass). Large breasts can place a great deal of stress on the mid-back as well as the neck and low back. Wearing a high- quality support bra or having a breast reduction may be appropriate management options for this population.
Hormone levels and variability represents a physiological difference between genders, as levels vary significantly more throughout a woman’s life than a man's. This is particularly true of estrogen, especially from the time menstruation starts (called menarche), sometime between ages 9- 14 years, and menopause. Menopause typically occurs between 49-52 years of age, which is triggered by a decrease in hormone production by the ovaries. (Note: a total hysterectomy— which includes removal of the ovaries—creates premature menopause.)
During adolescence, growth spurts are common and idiopathic scoliosis or an abnormal curvature of the spine can develop. The term “idiopathic” means the cause is unknown, and why women are three-times more likely to develop scoliosis than men is also a mystery. Treatment may range from a “wait and watch” approach to specific manual therapies and posture correction options that may include heel lifts for a short leg, foot orthotics for hyper-pronation of the ankles, as well as specific exercises for forward head carriage. Bracing may be needed if curves exceed 40 degrees although this varies on a case-by- case basis.
We will continue this important discussion next month—stay tuned!
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This information should not be substituted for medical or chiropractic advice. Any and all health care concerns, decisions, and actions must be done through the advice and counsel of a health care professional who is familiar with your updated medical history.