Monthly Pain Updates – March 2022

Low back pain (LBP) is a very common condition that many attempt to self-manage prior to seeking treatment at their local chiropractic office. One approach that an individual with LBP may reach for, especially if it helps keep them working, is a low back belt or brace. A 2008 systematic review concluded that lumbar belt use is not likely to prevent back pain, but what about the patient who already has LBP? Can a low back belt/brace benefit the LBP patient or does it unnecessarily prolong the patient’s pain and disability?

In a 2021 study, researchers asked 30 office workers (15 with LBP and 15 without LBP) to perform sit-to-stand movements while wearing either an extensible lumbar belt, a non-extensible lumbar belt, and no lumbar belt at all. With the aid of 3D motion analysis and a force plate, the research team observed that lumbar belt use provided benefits with respect to lumbar lordosis and total trunk range of motion in all participants. With respect to those with LBP, belt use reduced pain intensity, pain-related anxiety, and fear or movement. Interestingly, the results did not favor one type of lumbar belt over another.

It's important to note that prolonged use of a lumbar belt may not benefit the patient in the long-term. This is because bracing can restrict normal movement and weaken the deep muscles that help to stabilize the spine. This is similar to the reasoning in treatment guidelines for back pain that encourage movement and discourage prolonged bed rest and inactivity.

The authors of the study note that the average person performs sit-to-stand movements over 60 times a day, which accounts for 56-64% of total lumbar sagittal mobility. Because a low back condition can make sitting and standing painful and/or difficult, the temporary use of a lumbar belt may benefit the LBP patient while they’re under care to address their musculoskeletal disorder (of which chiropractic care is a great choice).

While additional studies are needed before firm conclusions can be made and treatment guidelines can be adjusted with respect to lumbar belt use for the patient with LPB, it’s worth noting that treatment guidelines also recommend that providers assess each patient individually and apply treatment strategies they feel will benefit the patient. Doctors of chiropractic will often tailor a patient’s treatment recommendations based on examination findings, the patient’s history, and other factors unique to the patient. This may include the use of a lumbar belt if it may help a patient return to their normal activities.

Neck Pain / Headaches

The Headache, Neck Pain, and Jaw Pain Trio

Temporomandibular dysfunction (TMD) is a painful and disabling condition that affects the joints, muscles, and nerves of the jaw. Those who suffer with TMD experience challenges with opening their mouth, which can make eating solid food impossible or even semi-solid or soft foods challenging. Patients with TMD often experience sharp pain when yawning, and even breathing through the mouth can be uncomfortable in some cases. It’s also common for the TMD patient to have trouble sleeping and concentrating, which can make it more difficult to carry out their daily living and work activities. Even worse, TMD can co-occur with neck pain and headaches. These compounded complications can really take a toll on a patient’s quality of life. Let’s discuss how chiropractic care can benefit the patient with this bothersome trio of conditions.

The current research suggests that the relationship between TMD and headaches/neck pain is potentially bidirectional. That is, dysfunction in the neck may increase the risk for TMD, and likewise, TMD may elevate one’s risk for neck pain/headaches. One study that included 116 adults found that those with TMD were significantly more likely to have cervicogenic headaches. Additionally, examinations of 60 TMD patients revealed that most experienced moderate-to-severe impairments in cervical function. Another study found that treatment applied to the temporomandibular joint can improve cervical function in patients with non-specific neck pain. Hence the importance of conducting a thorough examination of patients with jaw and/or neck pain to identify contributing factors beyond the area of chief complaint.

If the function of the temporomandibular joint itself is impaired, a doctor of chiropractic may apply manual therapies, like mobilization, to restore motion to the joint. Treatment may also focus on improving the function of the masticatory, masseter, and temporalis muscles that play a role in chewing and opening and closing the mouth. This can be accomplished with soft tissue therapies and/or myofascial release depending on the patient’s unique case. A systematic review found that these treatments are as effective as botulinum toxin injections to relax the affected muscles.

To address cervical dysfunction, a doctor of chiropractic may use a combination of manual therapies, like spinal manipulation and mobilization, along with specific exercises to address weakness in the deep neck muscles that help stabilize the cervical spine. Treatment may extend to the upper back and shoulders as musculoskeletal disorders in these body sites can affect the function on the neck, leading to neck pain and headaches.

Fortunately, these treatments can be applied concurrently, which can provide patients with faster and potentially more satisfactory results. A study that included 38 patients with chronic cervicogenic headaches and TMD found that the combination of orofacial and cervical manual therapies resulted in better short-term and long-term results than cervical manual therapy treatment alone. Additionally, the inclusion of at-home exercises for the jaw and neck muscles may lead to better outcomes with respect to pain and disability.

Chiropractic is a great treatment option for patients suffering from the unhappy trio of TMD, neck pain, and headaches. If necessary, your doctor of chiropractic can co-manage your condition with your dentist and/or medical physician.

Joint Pain

Greater Trochanteric Pain Syndrome

The bone you feel when you put your hand on your hip is called the greater trochanter, and it serves as an important attachment point for several muscles that move the hip in multiple directions. Greater trochanteric pain syndrome (GTPS) is a general term that has been used to describe multiple disorders that cause lateral hip pain. While trauma is a possible cause of GTPS, the condition is most often the result of overuse and repetitive friction between the muscle tendons that sprain over time, leading to tendonitis and subsequently bursitis—most commonly in women between 40 and 60 years of age. Two specific conditions that are often associated with GTPS are trochanteric bursitis and external coxa saltans.

Trochanteric bursitis involves any of the three bursa that surround the greater trochanter located on the front, back, and top of the bony prominence near the four facets where muscle tendons attach. Historically, most patients who present with lateral hip pain are diagnosed with trochanteric bursitis or inflammation of the subgluteal bursae located deep to the iliotibial band and abductor tendons (which moves the hip outwards). However, studies have found that GTPS almost always (92% from one study of 877 patients) involves BOTH tendonitis and bursitis simultaneously, rarely either one alone.

External coxa saltans, better known as “snapping hip” is typically caused by one or two muscle tendons snapping as they ride over the greater trochanter usually during hip movements including swinging the leg forward and backward (think running or punting a football) or during internal and external rotation (think kicking a soccer ball). Interestingly, snapping hip can be painless, but if inflammation of the bursae occurs, the patient can feel lateral hip pain, which in the presence of the snapping tendon makes for a fairly easy diagnosis.

When a patient presents with lateral hip pain, a doctor of chiropractic will perform several tests to reproduce pain over the greater trochanter. X-ray, ultrasound, and MRI may also be utilized to confirm diagnosis and to rule out other causes of hip pain.

Chiropractic care for GTPS is often successful and may include multiple approaches such as manual therapy of the hip, leg, and/or low back regions; leg-length correction with heel lifts; PT modalities such as pulsed ultrasound, electric stim, laser, pulsed magnetic field, and shockwave therapy; exercise training; and activity modification education. For stubborn cases, your chiropractor may refer you for an injection of either cortisone or plasma-rich protein (PRP). On rare occasions, surgery may be appropriate.

Carpal Tunnel Syndrome

Mechanical Wrist Traction for Carpal Tunnel Syndrome

Treatment guidelines for carpal tunnel syndrome (CTS) encourage patients to utilize non-surgical options before consulting with a surgeon, of which chiropractic care is an excellent choice. To manage the patient with carpal tunnel syndrome, a doctor of chiropractic will take a multimodal approach—that is, they will combine several therapies in order to achieve an optimal treatment outcome. One tool that may be incorporated into care is mechanical wrist traction.

In simple terms, mechanical wrist traction is a process by which a device is utilized to pull the hand away from the arm to elongate the tissues between, namely those in the carpal tunnel. It’s believed this reduces pressure in the wrist and facilitates nerve mobility.

In a 2017 study that included 181 CTS patients, participants received either 12 treatments of mechanical wrist traction twice a week for six weeks or usual medical care. The protocol for mechanical traction involved using weights that range from 1-18 kg on the affected hand for ten to fifteen minutes per session, depending on the patient’s comfort level. Patients in the care-as-usual group received a combination of wrist splinting and local corticosteroid injection.

The researchers monitored the patients’ progress for six months and found that 43% of the usual care group progressed to surgery compared with just 28% of the traction group. A follow-up study published in 2021 found that participants in the traction group continued to be less likely to require surgical intervention (44% vs 37%). Additionally, patients in the traction group were about 2.5 times less likely to drop out, suggesting they were more satisfied with their care than those in the usual care group. The authors concluded that mechanical traction is an effective non-surgical, conservative treatment option for the CTS patient.

In addition to conservative treatment to improve nerve mobility and reduce inflammation in the wrist, doctors of chiropractic will also examine the full course of the median nerve as it travels from the neck to the hand. This serves two purposes: 1) symptoms like numbness, tingling, pain, and weakness in the hand can also result from dysfunction in the neck, shoulder, elbow, and forearm; 2) CTS can co-occur with other conditions that affect the function of the median nerve, and treatment to resolve both issues may be necessary to achieve a satisfactory result.

Whiplash

Are X-Rays Always Necessary for Whiplash?

X-ray has been a very important diagnostic tool since its discovery by W.C. Röntgen in 1895. It provided a non-invasive means to peer inside the body, which opened the doors to better diagnostic and treatment decisions by clinicians. Over 100 years later, x-rays are still in common use in healthcare settings, including chiropractic offices, to assess the cervical spine in patients with whiplash associated disorders (WAD) and neck pain in general. But should x-rays always be used or are there instances when taking films should be avoided?

In a study published in 2002 that looked at data from Canada’s healthcare system, researchers reported that 200,000 cervical spine x-rays are taken of individuals injured by blunt or secondary trauma to the neck each year. Avoiding radiographs for patients who are likely to have results that are normal would reduce the financial burden on the healthcare system and at the same time reduce the patient’s exposure to ionizing radiation.

The obvious reason for taking x-rays for a patient with WAD is to rule out a fracture that could result in a devastating or life-threatening injury, such as spinal cord trauma when cervical instability is present. One common guideline recommendation supporting the use of plain film xray has been trauma resulting in midline posterior neck tenderness if there’s the possibility of fracture.

Clinical decision rules have been published in both Canada and the United States to help identify sub-groups of patients that may not require x-rays such as WAD I (symptoms without exam findings) and some WAD II (symptoms with non-neurological exam findings) injuries where the history and physical examination can quite clearly exclude significant pathology.

The Canadian C-Spine Study, which included over 14,000 patients, identified the following risk factors to warrant supervised cervical range of motion x-rays: age over 65 years; a defined dangerous mechanism of injury (evident head/neck trauma); any sensory abnormality or focal neurologic deficit in the extremities; altered level of consciousness, intoxication, or evidence of facial or external head injury when examination of the neck is unreliable, such as other distracting painful injuries; when active rotation ROM cannot be performed by the patient in a defined manner; and if fracture or instability is suspect.

As you can see, x-rays are not always necessary when it comes to patients with neck pain, whether from whiplash or not, so if your doctor of chiropractor does not take films as part of your initial examination, there may be good reason.

Whole Body Health

Music and the Brain

Music can have a variety of effects on an individual from altering their mood to triggering a memory. But did you know that music can also play a role in protecting the brain and helping it function?

In 2020, the Global Council on Brain Health (GCBH) gathered a panel of experts to examine the latest research on how music affects and influences brain health. There was strong agreement among the experts that music can play a vital role in promoting mental well-being, increasing social connections, and stimulating cognitive skills—all of which can slow the progression of or even reduce the risk for Alzheimer’s disease.

One of the GCBH panel’s main recommendations is to actively engage in singing and/or dancing as these activities provide both physical exercise as well as being a highly effective stress reducer. Although studies show that the strongest response to the brain (and dopamine release) occurs when the music is familiar and enjoyed, listening to new music can also stimulate the brain.

For patients with mild-cognitive impairment or dementia, even its later stages, music therapy has been found to improve mood and quality of life and reduce anxiety and depression as well as agitation. There is also data to suggest that patients with Parkinson’s disease may experience a better ability to talk and move when listening to music. It has even been demonstrated that music, especially singing, can help during recovery from a stroke.

In addition to singing in the shower or in the car, look for more ways to work music into your life. Some suggestions include using apps to suggest new bands or songs that you may enjoy, creating a playlist of songs that are motivating, joining a choir, learning an instrument, and taking dance classes.

Of course, if you find that musculoskeletal pain interferes with your ability to comfortably carry out these musical activities, contact your doctor of chiropractic. The sooner you seek care, the faster you may resume your normal activities.