Monthly Pain Update – September 2022

Chiropractic Management of Low Back Pain

The approach a doctor of chiropractic will take to manage low back pain will differ depending if the injury is new (acute), recent (subacute), or has persisted for three months or longer (chronic). Though some management tools overlap between each group, each stage of injury includes unique challenges that require specific interventions.

ACUTE LOW BACK PAIN: In this stage, it’s important to address inflammation and to avoid aggravating the injury, which can hinder recovery. Chiropractic pain management strategies include a multi-modal care approach that can include manual therapies (spinal manipulation, mobilization, stretching, massage, and more), tools to reduce inflammation (ice, topical agents, electric stim, laser), muscle relaxing techniques (dry needling and acupuncture), at-home exercise, and nutrition/diet recommendations (anti-inflammatory diet, turmeric, Boswellia, omega-3 fatty acids, vitamin D3, etc.). Importantly, the patient must be assured that they can get better.

SUBACUTE LOW BACK PAIN: The management strategy and treatment goals at this stage are similar to the acute stage, but the intensity of care may be increased. The patient may also receive instruction on muscle strengthening exercises specific to their case, and they should maintain normal activities as much as possible so that the condition does not become chronic and more challenging.

CHRONIC LOW BACK PAIN:  In the chronic phase, the patient may have changed their movement patterns to avoid pain, which may place adjacent tissues and other areas of the body at risk for injury. They may also be hesitant to return to their previous lifestyle out of fear of making their pain worse, causing them to give up a hobby or even change careers. This can lead to depression and anxiety, which may need to be co-managed with an allied healthcare provider. At this stage, the key is to restore normal joint motion, address faulty mechanics, strengthen muscles that have atrophied, and encourage the patient to resume their normal lifestyle and activities.

Following the conclusion of care, the patient may also find that routine visits to their chiropractor can help them reduce their risk for a future episode.

Neck Pain and Cervical Disk Derangements

There are several musculoskeletal disorders associated with the disks of the cervical spine that can cause pain and affect function. Let’s discuss the various types of these pain-generating disk derangements, including one that had been ignored until recently.

The intervertebral disk is a fibroelastic cartilaginous shock absorber that sits between two vertebral bodies, which are the large boney parts of the spine that bear most of our body’s weight and are stacked on top of each other like building blocks. The center of the disk (called the nucleus) is mostly water, and it acts like a ball bearing, facilitating movement. Surrounding the nucleus is the annulus, which is made up of tough, dense, and strong cartilaginous fibers. There are six intervertebral disks in the cervical spine. Under normal loads, the nucleus absorbs shock with its forces pushing up and down into the vertebral body endplates and outwards into the annulus as move.

Unfortunately, as we age and depending on our lifestyle choices, the structure of the cervical disks can weaken, the annulus can tear, and part of the nucleus can leak into or beyond the annulus. This may be referred to as disk herniation, protrusion, extrusion, or sequestration. In some cases, this can occur in such a way that the protruding nucleus does not cause pain, which is something that is commonly seen on MRI scans of asymptomatic individuals.

However, in other instances, the bulging disk may press against a nerve root, creating pain that shoots down the course of the nerve. In the case of the cervical spine, pain may follow down through the arm and into the hand. The outer edge of the annulus also has a nerve and blood supply, so injury to the annulus can cause localized pain. Additionally, these nerves and blood vessels can proliferate deeper into an injured disk, leading to pain in the immediate area.

Researchers have also observed that the force of the disk pushing into the endplates of the vertebral bodies both above and below can lead to a fracture known as Schmorl’s node. It’s long been thought that these are painless, but a 2021 study that included 582 participants identified an association between Schmorl’s nodes in the cervical spine and local, non-radiating neck pain.

Chiropractic care offers a conservative multi-modal treatment approach that has been found to be highly effective for managing patients with neck pain arising from multiple sources, including cervical disk injury.

Preventing Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is a condition associated with pain, numbness, tingling, and weakness in the wrist and parts of the hand, which is caused by compression of the median nerve as it passes through the wrist. Due to this common condition having such a dramatic effect on one’s ability to carry out work and activities, one may wonder if CTS can be prevented. The short answer is… maybe.

Unfortunately, CTS doesn’t just have one primary cause. Rather, patients often have multiple health conditions and lifestyle factors that may each increase the risk for the complaint. Because many of these individual risk factors are unavoidable, it’s not possible to eliminate one’s risk for the CTS. However, that’s not to say there aren’t steps that could lower one’s risk for the condition:

• Eat a high-quality diet: Because inflammation can reduce the space in the carpal tunnel, eating an anti-inflammatory diet—such as the Mediterranean diet—that is rich with fruit and vegetables and avoids high fat, high carb processed foods may help to reduce CTS risk.
• Get exercise: In addition to keeping the joints healthy and muscles strong, exercise can reduce stress and provides anti-inflammatory effects.
• Don’t smoke: In addition to hindering the delivery of oxygen and nutrients to the cells, smoking may slow healing and even increase the risk of injury to the soft tissues in the body, including those in and near the wrist.
• Manage chronic disease: Conditions that affect hormone levels like diabetes and hypothyroidism have been linked to CTS, so taking steps to manage these conditions should lower the risk for CTS.
• Activity modifications: Frequent, repetitive movements—especially those which involve awkward wrist movements/posture—can cause inflammation in the wrist. Taking frequent breaks, rotating activities, and using more wrist-friendly tools can help.
• Address other musculoskeletal disorders: Patients with CTS frequently have musculoskeletal issues elsewhere along the course of the median nerve (the neck, shoulder, elbow, and forearm) that can increase the risk for median nerve restriction in the wrist.

While these actions may help to lower the risk for CTS, sometimes the condition is unavoidable. However, the current research suggests that CTS is much easier to manage and a patient is more likely to have a satisfactory result the sooner they seek care. So don’t wait until your symptoms worsen before contacting your doctor of chiropractic!

Managing Osteoarthritis of the Knee or Hip

Osteoarthritis is a common chronic joint condition that affects roughly 10% of adults in the United States. Because it’s associated with obesity and advancing age, the condition is becoming more and more common. Two of the most common parts of the body affected by osteoarthritis include the hips and knees, which can cause considerable disability and dramatically affect one’s quality of life. Doctors of chiropractic use a variety of treatment approaches to manage musculoskeletal disorders, which includes supervised exercises and manual therapies. Is there a way to know which approach might be most beneficial for the hip or knee osteoarthritis patient?

In a study published in 2013, researchers sought to answer this question by recruiting 206 older adults who were under physician care and on a waitlist for surgery to address hip or knee osteoarthritis. The participants were separated into four groups: 1) manual therapy plus usual care; 2) supervised exercise plus usual care; 3) manual therapy plus supervised exercise and usual care; 4) usual care only. To track results, the researchers used the evidenced-based Western Ontario and McMaster Osteoarthritis Index (WOMAC) questionnaire, administering it at the start of the study, during the 16-week treatment phase (which included nine treatment sessions), at the conclusion of care, and one year later. Participants also underwent physical performance tests to track functional improvement.

The WOMAC uses a 0 (no disability) to 241-point (full disability) scale, of which all participants averaged a 100.8 score, indicating 42% disability. While WOMAC scores crept slightly upward in the usual care only group, the participants in the three treatment groups experienced improvement with disability falling to an average of 12%, 7%, and 6% disability in groups 1, 2, and 3, respectively.

The authors conclude that supervised exercises and manual therapies are superior to no treatment for patients with knee or hip osteoarthritis. Doctors of chiropractic often use a multimodal approach that includes both exercises and manual therapies for the management of musculoskeletal conditions, including osteoarthritis. Because each patient’s case is unique and they may respond differently to care, a chiropractor will monitor the patient’s progress and if necessary, modify their treatment approach for the purpose of reducing pain and disability to the greatest extent possible.

The Spinal Cord and Whiplash Injuries

When a whiplash event occurs—such as a motor vehicle collision—the rapid back and forth motion of the head can injure the bones, muscles, ligaments, joints, and nerves (including the spinal cord) in the neck leading to the collection of symptoms known as whiplash associated disorders (WAD).  While about 50% of those injured can expect a rapid recovery, the other half has longer term complaints, which may include neck pain, headache, widespread sensory hypersensitivity, psychological distress, and changes in motor performance, cognitive function, and muscle composition. One highly frustrating aspect of WAD injuries is the lack of objective tests to make a firm diagnosis. However, a recent study may have identified a new tool in diagnosing injury to the spinal cord, which may help identify patients at risk for ongoing issues.

Routine x-ray is not sensitive enough to pick up cord-related injury in the absence of obvious fracture or dislocation. Though there are some clinical exam tests that can help identify minor spinal cord injury such as heightened reflexes and abnormal brain/cord-related superficial reflex signs, a new study describes an advanced MRI method, magnetization transfer imaging (MTI), that can quantify a discrete cord injury.  Of the seventy-six WAD patients in the study, thirty reported complete recovery at the one-year point, thirty-two continued to experience mild symptoms, and fourteen had severe ongoing symptoms. A review of each patient’s initial neck disability index (NDI) questionnaire revealed that the patients who did not recover had higher pain and disability scores early on. However, there was no difference in initial NDI scores in the mild/severe one-year symptom groups.

The researchers then used MTI to look for signs of injury in different tracts of the spinal cord and found differences in the areas that transfer motor and sensory information between all three groups. Investigators add that abnormal findings were more common among the female participants, as women are nearly two times more likely to develop chronic WAD. It’s suspected this may be due to anatomical differences between male and female necks with respect to muscle mass and length.

Chiropractors routinely utilize questionnaires such as the NDI and clinical neurological reflex tests to track a patient’s course of care and response to treatment. When signs and symptoms persist, advanced imaging such as MRI can shed additional light as to why those patients have not recovered. Until MTI becomes more available, reliance on the current diagnostic tools (questionnaires and clinical exam) will continue to be the standard.

The good news is that there are MANY clinical studies that support chiropractic’s multi-modal treatment approach in the management of WA that includes manual therapies (manipulation, mobilization, soft tissue release techniques, etc.), physical modalities that promote healing, exercise training for soft tissue strengthening, and neurological recovery (balance, visual disturbances, light/noise sensitivity, etc.). As technologies continue to advance and become more readily available, healthcare providers will be able to better identify physical reasons for ongoing pain and provide appropriate interventions in attempt to prevent chronic, long-term complaints.

Reducing Kidney Stone Risk

When a patient seeks chiropractic care to address acute back pain, the cause is usually musculoskeletal in origin. However, if changing body positions (leaning forward or back or turning to the side, etc.) has no effect on pain levels, there’s a possibility the underlying cause of their sudden back pain may be a kidney stone. Let’s discuss kidney stone causes and prevention.

Kidney stones (technically called renal calculi, nephrolithiasis, or urolithiasis) are hard deposits made of minerals and salts that form inside the kidneys, and they affect about 9% of citizens in Western nations. There are several risk factors associated with kidney stones such as a family or personal history of prior stones; dehydration (think dry/hot climates; excessive sweating); a high-protein diet (like the Dukan diet); excessive sodium (salt) and sugar; digestive diseases (chronic diarrhea, gastric bypass); a medical condition like renal tubular acidosis, cystinuria, hyperparathyroidism, repeated urinary tract infections, and more; certain supplements and medications such as vitamin C, dietary supplements, laxatives (excessive use), calcium-based antacids, certain migraine medications, depression medications, and more.

When stones form in the kidney, they can vary significantly in size. Generally, only the smaller stones pass, and when this happens, it can be quite painful. The “good” news is that most of time, there is no permanent damage. In the event of passing a stone, it’s important to keep it for analysis as it will reveal the underlying cause. Identifying the cause can help reduce the risk of recurrence, which can be as high as 50% within five years!

If a stone becomes lodged, the diagnosis must be made in a timely fashion to avoid damage. Depending on the situation, you may need nothing more than pain medication and a lot of water, but if the pain does not subside, a urinary tract infection or other complications can arise that may require surgery.

The authors of a 2022 study noted that kidney stones should be viewed as a systemic disorder, associated with or predictive of hypertension, insulin resistance, chronic kidney disease (CKD), and cardiovascular damage (CD). They HIGHLY recommended screening kidney stone patients for both CKD and CD (stating that this is infrequently done). They emphasized that each patient be given a patient-tailored plan based on the clinical and lab/biochemistry evaluation results and AVOID giving excessive dietary restrictions especially if not based on a specific diagnosis to prevent potentially useless or even harmful results.

The good news is that by living a healthy lifestyle and avoiding the risk factors listed above, you can reduce the risk for a kidney stone.

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This information should not be substituted for medical or chiropractic advice. Any and all healthcare concerns, decisions, and actions must be done through the advice and counsel of a healthcare professional who is familiar with your updated medical history.