Monthly Pain Update – July 2024

Gardening Tips to Avoid Low Back Pain  

Low back pain and gardening seem to go hand in hand, especially getting the garden ready after a long sedentary winter! As many people who love gardening know, keeping up with the weeds through the summer can also take its toll on the low back. Let’s take a look at ways to minimize low back pain or injury!

• Try out no-till gardening to keep weeds at bay.
• Raised garden beds mean less bending over and reaching.
• Plant perennials. They keep on giving each year!
• Rotate between tasks that require different body positions. Determine what time interval works best for your back (rotate every two, three, or five minutes). This avoids prolonged static faulty postures that can lead to an aching back!
• Set the timer on your phone to remind you when it’s time to stretch (try every 5 to 10 minutes, for starters). Ask your chiropractor for specific stretches that are right for you as we all have different needs.
• Strengthening the core muscles can help prevent injury. Ask your chiropractor for tips on which exercises to try first.
• Bend with hip hinging! This is accomplished by bending the knees, poking the buttocks up so your low back maintains its inward (lordotic) curve as you bend and reach toward the ground. This minimizes lumbar spinal loading and spares compression of the intervertebral disks!
• When lifting heavy bags of mulch or potting soil, grasp opposite corners, drag the bag close to you, and pull it up onto your legs as a shelf while hip hinging before standing up and walking. Or use a wagon or garden cart to move the heavy bags.
• Keep objects you’re lifting close to you to reduce the load on the low back.
• Kneel if your knees can handle it and support your weight with one arm while the other is working. Use a boat cushion or some other padding to minimize pressure under the kneecaps to avoid knee bursitis and pain.
• Sit on the ground. Get the weight off the low back and change positions frequently.
• Consider long, full length tools over hand tools and/or rotate between them.

Lastly, before jumping back into gardening, go visit your doctor of chiropractic and get checked out. Studies have shown that chiropractic patients who attend wellness or maintenance visits report 12-13 fewer days with low back in the following year.

Treatment Options for Tennis Elbow

Lateral epicondylitis, more commonly known as tennis elbow, is a muscle tendon injury located on the thumb-side of the elbow. While the condition can result from a single traumatic event, tennis elbow is typically caused by repetitive motions that involve gripping or extending the wrist that overload the forearm muscles. Initially, the tennis elbow patient may pursue self-care options such as ice therapy, compression, rest, elevation, and over-the-counter pain relief medications and analgesics. However, if these approaches fail to yield a satisfactory result, the patient may have several treatment options they can pursue.

Cortisone injections are commonly used to provide short-term relief for lateral epicondylitis; however, this treatment is not without risk. The Mayo Clinic notes the following potential risks associated with cortisone shots: cartilage damage, death of nearby bone, joint infection, nerve damage, short-term fascial flushing, short-term joint irritation, short-term increase in blood sugar, tendon weakening/rupture, whitening/lightening of skin at injection site, and thinning of nearby bone, skin, and soft tissue at injection site. Because of these risks, most physicians put a limit on the number of cortisone shots given per year, depending on the diagnosis and other factors.

The good news is that a 2024 systematic review that included twelve studies concluded that a physical treatment approach provides longer-lasting benefits than cortisone shots, with limited risks (such as potential bruising in patients using blood thinners), and a lower recurrence rate. Examples of physical treatments include electrotherapy, manual therapy, and exercises—all treatments commonly provided in a chiropractic setting. Additionally, a systematic review that included patients who failed to respond to injections reported that low-level laser therapy—a technology many doctors of chiropractic utilize—can provide significant improvements in pain, grip strength, pain sensitivity, and ability to carry out work activities.

When managing lateral epicondylitis, doctors of chiropractic will often employ a multimodal approach that combines several of these therapies, as often doing so yields superior results for the patient vs. one isolated therapy. Chiropractors will also look at the whole patient to identify any issues beyond the forearm that could potentially contribute to the patient’s symptoms. Some examples include carpal tunnel syndrome, golfer’s elbow, rotator cuff tendinitis, De Quervain tenosynovitis, bursitis, shoulder impingement syndrome, and trigger finger. If a patient fails to respond to treatment, they may be referred to an allied healthcare provider to pursue more invasive treatment options. Fortunately, many patients respond well to conservative care.

The Importance of the Hamstrings

The hamstrings consist of four muscles in the back of the thigh and upper leg—the biceps femoris (long and short heads), semitendinosus, and semimembranosus—that connect the ischial tuberosity to the knee area. This collection of muscles performs a variety of functions including bending or flexing the knee joint; extending the hip joint; internal hip rotation; decelerating knee extension and hip flexion during high-velocity actions; and absorbing kinetic energy and protecting the knee and hip joints during walking. The state of the hamstrings can also contribute to musculoskeletal issues involving the knees, hips, and lower back.

In fact, hamstrings are a somewhat hot topic in the research community appearing in nearly 1,000 journal articles and studies in recent years, up from about 100 at the turn of the century. Several studies have noted an association between shortening or tightness of the hamstrings and abnormal lower limb biomechanics and sagittal (from the side) posture faults—all of which can place added stress and strain on nearby joints. Not only can this contribute to low back pain, knee pain, hip pain, etc., but tight hamstrings can also impair function, which can limit an individual’s ability to carry on their normal life (and sport) activities.

While it’s not entirely clear about the nature of the relationship between tight hamstrings and musculoskeletal disorders like low back pain—that is, does hamstring shortening lead to low back pain or does inactivity in response to low back pain lead to tight hamstrings—at least one study reported that industrial workers who participated in a three-minute daily exercise routine that included hamstring stretching experienced a 40% reduction in low back pain within three months. Hence the importance of daily stretching, especially for individuals who work at a desk or spend a lot of time engaged in sedentary activities.

When tight hamstrings are observed in patients with chronic musculoskeletal disorders, like chronic low back pain, doctors of chiropractic can employ several in-office therapies to improve hamstring flexibility. It’s also important to ensure hamstring flexibility is similar in both legs as a 2023 study found that hamstring flexibility imbalances can also contribute to low back pain. Some of these treatment options include myofascial release, soft tissue mobilization, passive stretching, and proprioceptive neuromuscular facilitation stretching.

To facilitate the healing process, patients will be provided with instruction on stretches they can perform on their own throughout the day. Some commonly recommended stretches include placing the heel/foot on a chair and keep leg/knee straight while arching the low back and leaning forward; raising the knee to the chest, grasping behind the knee, and slowly straighten the leg; and placing the leg on a foam roller and rolling it forward and backward from the knee to the buttocks.

Manual Therapy Options for Cervicogenic Headaches

Cervicogenic headaches are a form of secondary headache resulting from dysfunction in the cervical spine—typically, the upper most part of the cervical spine (atlanto-occipital joint) and upper three cervical segments (C1-3). Dominant symptoms and signs include unilateral head and upper neck pain, limited neck motion, and increased symptoms with certain neck and head positions. It’s estimated that cervicogenic headaches affect between 2% and 4% of the population; however, among patients with chronic headaches, the prevalence is upward of 20%.

Clinical treatment guidelines include the use of manual therapy as a first treatment option for the management of patients with cervicogenic headaches, though no specific recommendations have been made regarding which type of manual therapy is most effective. Chiropractors perform manual therapies more than any other profession including manipulation (thrust) and mobilization (non-thrust) with the goal of restoring motion and reducing pain and disability. Some studies have favored mobilization over manipulation for improving headache intensity, frequency, and duration while others have come to the opposite conclusion. Because each patient’s case is unique, the decision on which type of manual therapy to employ should be based on the clinician’s discretion.

Ultimately, treatment will likely include several manual therapies and address musculoskeletal issues beyond the cervical spine that may be contributing to their chief complaint. Such issues may include temporomandibular disorders, upper cross syndrome, forward head posture, or musculoskeletal disorders involving the thoracic spine and scapula. In addition to manual therapies, neck-specific exercises have also been demonstrated to benefit the cervicogenic headache patient, though much like manual therapies, the decision on which specific exercises to use is often left to the healthcare provider to decide.

Interestingly, researchers have observed that dysfunction in the neck may also play a role in other forms of headache. For example, a systematic review of 13 studies published in 2022 concluded that mobilization techniques, trigger point therapy, manual lymphatic drainage, massage, and stretching techniques each benefit migraine headache patients—especially when used in combination. So, if you suffer from headaches and your current treatment plan isn’t providing the relief you would hope for, consider consulting with a doctor of chiropractic to see if manual therapies applied to the cervical spine region may be of benefit.

Chiropractic Evaluation of Whiplash

Whiplash associated disorders is a term used to characterize the constellation of signs and symptoms that commonly result from the rapid acceleration and deceleration of the head and neck, most often from motor vehicle collisions. Whether from the recommendation of a friend, family member, or personal injury attorney or from a self-referral after other treatment approaches fail to yield a satisfactory result, many whiplash patients may find themselves visiting a chiropractic office.

When the patient first arrives, they will be greeted and asked to complete paperwork regarding their motor vehicle collision including immediate and delayed symptom onset, road/weather conditions, and collision specifics (speed, direction of impact, multiple impacts, head position at time of impact, airbag deployment, size of vehicles involved, and more). They may also be asked to note on a drawing of the human body where they feel pain (a pain diagram) and fill out questionnaires regarding musculoskeletal and mood symptoms, as well as their personal health and family history.

The data provided by the patient will guide the physical examination. This may include an evaluation of posture from a standing position focused on the occiput (skull), shoulders, iliac crests (pelvis), the hip/knee/ankle/foot angles; from the side to evaluate forward head posture, shoulder protraction, sway or arched low back, hip/knee/ankle position; and a gait analysis, looking for asymmetrical movement patterns. Each area of complaint will undergo palpation (touch sensitivity, heat/pain), range of motion, pain provocation and reducing tests, and a neurological examination. If warranted, the chiropractor may order X-rays and/or advanced imaging (like an MRI, CT scan, or ultrasound).

The treatment plan will be tailored to the patient’s unique case but will likely be multimodal in nature and include manual therapies (manipulation, mobilization, myofascial release, etc.) and physio-therapeutic modalities (electric stim, ultrasound, laser, cervical traction, dry needling/acupuncture, etc.) provided in the office along with at-home exercise, ice instruction, and recommendations to carry out usual activities within reasonable pain boundaries.

The frequency of visits can vary, but it’s common for patients to be seen more frequently initially with the number of visits per week reduced over time. The patient’s progress will be monitored until they achieve the maximum possible improvement. If the patient does not respond well to treatment, the chiropractor may alter their approach and/or refer the patient to an allied healthcare provider to perform services outside their scope of care. The good news is that whiplash patients often respond well to chiropractic treatment!

Dietary Strategies for Healthier Bones

Bone is a living tissue that naturally and continuously breaks down (osteoclastic activity) and is replaced (osteoblastic activity). Peak bone mass is achieved at around age 30 with breakdown accelerating thereafter. If sufficient bone mass and microstructure is lost, an individual may be diagnosed with a condition known as osteoporosis. Osteoporosis can affect both men and women; however, the condition is significantly more common in women, particularly following menopause in response to hormonal shifting. There is presently no cure for osteoporosis, rather the current treatment approach is to slow the disease process. One such approach involves dietary strategies.

The current literature suggests the following types of food should be avoided in individuals with or at risk for osteoporosis: high-sodium foods like bread/rolls, sandwiches, pizza, soups, lunch meat, burritos, tacos, chicken, cheese, eggs, chips, and pretzels; red and processed meat (especially with high levels of saturated fat and omega-6 fatty acids) like beef, hamburger, hot dogs, sausage, and bacon; ultra-processed food products; sugary, caffeinated, and/or alcoholic beverages; oxalate-rich foods like leafy greens and legumes (soaking or boiling can remove oxalates); and wheat bran. Each of these food and beverage choices may have one or more of the following effects on bone health: increased calcium excretion in urine, increased bone resorption, increased inflammation, reduced calcium absorption, and calcium leaching from bone. Unfortunately, these types of food and drink are characteristic of the typical Western diet.

On the other hand, an eating pattern like the Mediterranean diet that focuses on fruit, vegetables, nuts, fish, olive oil, and whole grains while avoiding red and processed meats, dairy, saturated fats, and refined sugars may benefit bone health. It’s been observed that greater adherence to the Mediterranean diet is associated with less bone loss in the hip, higher bone mineral density in the lumbar spine, and a lower risk for developing osteoporosis. It’s suspected these benefits are linked to reduced bone resorption, reduced oxidative stress and inflammation, and improved calcium absorption. Studies also support the use of vitamin D and calcium supplements for healthier bones.

Ultimately, dietary changes alone may not be enough for individuals with or at risk for osteoporosis to reduce their risk for serious bone fractures.  Additional lifestyle choices include not smoking, spending more time outdoors in parks and nature, engaging in weightbearing exercises, lifting weights, and getting sufficient quality sleep each night. If you’re fortunate enough to be reading this at a young age, be sure to exercise during adolescence, including participating in high-impact sports, which may provide life-long bone health benefits.

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.