Monthly Pain Updates – April 2022
Low Back Pain
The Pillow Challenge for Neck Pain Patients
For the patient with neck pain, getting a good night’s sleep is vital for recovery and lowering the risk for transition to chronic neck pain. Likewise, for the individual with a history of neck pain, sufficient quality sleep is important to reduce the risk for recurrence. With respect to the cervical spine, the choice of pillow can be a critical factor in this regard, so let’s take a look at what considerations one should make when selecting the best pillow and why this can be a challenging process.
In 2021, researchers looked at current trends and research methods regarding the ergonomic considerations for pillows with the understanding that the head and neck require proper support to reduce stress on the cervical spine, the intervertebral disks, and the muscles in the neck, upper back, and shoulder regions. The research team noted that many studies use subjective participant reports as a way characterize the effectiveness of a pillow on supporting the head and neck, which may not provide the most accurate and meaningful data.
However, they did report on experiments that used more objective means. In one study, participants laid on a pressure-sensitive mat with 1,024 sensors to measure pressure distributions of the head, neck, chest, waist, and hips. The authors of this study noted that as the thickness of the pillow increased, there was a corresponding rise in cervical and cranial pressure. Additionally, a study that utilized electromyography (EMG) showed greater muscle activity while side laying when a pillow was 5 cm or 14 cm thick than a 10 cm thick pillow. Other research has shown that a pillow too high or low can also affect spinal alignment as seen on x-ray.
With respect to materials, one study found that a pillow that better maintains its shape (a springy foam material, for example) may be better for relieving neck pain than a softer pillow more prone to flattening, especially as the night progresses.
One problem that the neck pain patient (or anyone for that matter) will encounter when choosing the appropriate pillow for sleep is that sleep is a dynamic process in which unconscious sleep posture change occurs about 24 times a night, mostly between supine and lateral positions to relieve fatigue. Even if a pillow appears to properly support the head and neck when laying on one’s back, the same pillow may not be the best fit when they transition to sleeping on their side.
In the future, we’ll likely be able to purchase a pillow that can dynamically alter its thickness at various points based on the individual’s sleep position. But until then, the consumer is forced to find a pillow that best fits their anatomy and changing sleeping postures. The current research suggests that a proper height and firmness are important considerations. Another pillow characteristic to consider is the shape of the pillow, whether rectangular, u-shaped, or b-shaped. Fortunately, the neck pain patient can consult with their doctor of chiropractic for suggestions based on their unique case history. Their chiropractor may stock specialized pillows at the office or can order them on behalf of the patient, if necessary.
Neck Pain / Headaches
Pre-Surgical Actions to Improve Knee Replacement Outcomes
Osteoarthritis (OA) is a very common chronic disease that frequently affects the knees of the elderly. The condition usually has a slow onset that results in pain, limited mobility, and stiffness due to swelling of the joint capsule, loss of joint space, and for some, joint deformity. Treatment guidelines generally recommend non-surgical options—like chiropractic care—as a front-line approach, but if conservative care does not produce a satisfactory result or if the condition has already progressed to end-stage knee OA, then a patient may be a candidate for total knee arthroplasty (TKA).
However, TKA does not always produce satisfactory long-term results with many patients continuing to report knee pain and disability. This is especially true if they have either restricted knee range of motion or poor knee alignment. If surgery becomes unavoidable, is there anything the patient can do beforehand to improve their chances for a successful outcome?
Taking into account published studies that support exercise as a means to approve post-surgical outcomes for patients who had undergone TKA, a 2021 study investigated if a knee rehabilitation exercise program could benefit patients awaiting TKA. The study included 60 older women who exercised for 30 minutes per session twice a day for three weeks. Compared with women in a control group who did not exercise, the participants in the exercise group reported better outcomes six weeks following TKA with respect to leg strength, sit-to-stand test performance, and subjective pain and function. Another study found that pre-TKA exercise rehabilitation not only improved sit-to-stand performance and knee range of motion, it also shortened hospital stays.
When the knee is out of normal alignment, the joint may be subjected to increased stress. In addition to treatment to restore proper motion to the knee, musculoskeletal disorders that affect one’s gait—such as ankle pronation—may place added stress on the knee and would also need to be addressed.
For the patient who must have a knee replacement, the data indicate that pre-surgical exercise rehabilitation and efforts to improve knee alignment are a great idea. However, in a perfect world, the goal is to avoid surgery. For knee OA, a doctor of chiropractic may adopt a multimodal approach that can include the following: joint manipulation and mobilization, acupuncture, soft-tissue therapies, modalities (such as low-level laser and interferential current), exercise (including yoga), mind-body interventions (such as mindful meditation and cognitive behavioral therapy), and lifestyle modifications (such as diet and smoking cessation). If necessary, your chiropractor will co-manage the condition with an allied healthcare provider.
Joint Pain
Laser Therapy for Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is a condition that occurs when the mobility and function of the median nerve is restricted as it passes through the wrist, which can result in symptoms like pain, numbness, tingling, and weakness in parts of the hand and some fingers. To reduce inflammation, restore joint motion, and improve median nerve mobility, a doctor of chiropractic will adopt a multimodal approach to give the patient the best opportunity for recovery. One such option that the CTS patient may encounter in the chiropractic setting is laser therapy. Let’s discuss what laser therapy is and how it can benefit a patient under care for CTS.
Low-level laser therapy (LLLT), or class IIIb laser, was cleared for use by the United States Food and Drug Administration (FDA) in the early 1990s. Class IV or high-intensity laser therapy (HILT) received FDA clearance a decade later. By definition, LLLT includes lasers up to 500 mW while HILT are those above 500 mW. The primary difference is that HILT can penetrate further into the targeted tissue. Regardless of wattage, LLLT and HILT both emit energy in a specific range (600nm-1,000nm or from the red to near-infrared portion of the electromagnetic spectrum) that can penetrate the skin and stimulate reactions in the tissues to improve cellular function, which can reduce pain and accelerate healing.
A study published in 2020 that included 98 CTS patients found that when combined with specific exercises, both LLLT and HILT are more effective for reducing pain and improving motor function than specific exercises alone. Additionally, the study found that HILT was more effective in this regard, but LLLT improved nerve repair to a greater extent. A 2020 systematic review found that HILT may provide the most benefit for reducing pain when combined with other interventions for the management of musculoskeletal conditions, which includes CTS.
In addition to LLLT or HILT, a doctor of chiropractic may utilize other high- and low-tech tools like e-stim, pulsed electromagnetic field, ultrasound, dietary modifications/supplements, and ice/heat. How your doctor of chiropractic approaches your care will depend on your patient history and examination/diagnostic findings as well as their clinical experience. The good news is the conservative treatment approaches used by chiropractors are often very effective, but if necessary, your doctor of chiropractic can co-manage your condition with other healthcare providers.
Carpal Tunnel Syndrome
Whiplash Prevention Strategies that Benefit Everyone
Not only do whiplash associated disorders affect an individual’s health and wellbeing but they can also impact their family and society overall. With that in mind, let’s discuss strategies to reduce the prevalence of automobile collisions and the severity of injury when a car crash does occur.
On a community and government level, ways to reduce the risk for automobile collisions include: good road design that is large enough to handle rush-hour traffic with well-marked exits and entrances; increased access and use of mass transit options; the development and deployment of smart vehicles (self-drive technologies, adaptive speed cruise control, lane control); strategies to reduce the number of impaired drivers on the road; strict management of driver hours for commercial and public transport; and cameras at traffic lights.
There are also several ways an individual can lower their risk for a car accident. These include not speeding and only driving as fast as conditions allow when the weather is poor; allowing for extra space for the vehicle ahead of you; slowing for road work; not driving while tired or otherwise impaired; not being distracted while driving, such as texting or manipulating the radio; proper use of the turn signal; scanning for hazards in the road; not making rash decisions if you miss a turn or exit; and asking for a ride from friends or family members if you no longer feel safe behind the wheel due to illness, injury, or age.
Here are a few tips to reduce the risk for injury in the event of a collision: wear your seatbelt and don’t start the car until all passengers are buckled up; make sure children are secured in age- and size-appropriate restraints; ensure the vehicle has working airbags; don’t ignore vehicle recall notices; keep your car well-maintained, including the tires and brakes; keep the seat near upright and the head restraint at an appropriate height.
Additionally, lifestyle strategies like maintaining a healthy weight, eating a nutritious diet, getting adequate sleep, managing stress, and getting regular exercise may also reduce the risk for more severe whiplash injury. If present musculoskeletal aches and pain interfere with your ability to stay active and healthy, please contact your doctor of chiropractic and schedule an appointment.
Whiplash
A Better Type of Walking Shoe
While the advice to take 10,000 steps a day stems from a pedometer marketing campaign and did not originate from published research, it’s clear that a more active lifestyle (i.e. more steps per day) is better than a sedentary lifestyle. But what about the shoes we place on our feet when taking those steps? Are there shoe characteristics that may be best for the wearer?
A 2021 study looked at how six different footwear types affect contact force, bending, and torsional hip movements during treadmill use. The six shoe types included a barefoot shoe, an everyday shoe, a sports shoe, a men’s dress shoe, an unstable shoe, and a shoe with a stiffened sole. The investigators observed that the barefoot shoe placed the least load on the hip joint and on the heel. On the other hand, the stiffer and more cushioned the shoe, the more loading heel loading and torsion on the hip.
One might think it is strange that a stiff shoe and/or one with MORE cushioning would result in greater loading at the hip joint. The researchers behind the study speculate that a stiff sole shoe has limited flexibility and therefore transfers greater forces into the body. Cushioning can also hinder the proprioception of the foot sole as well as cause a degree of instability at the time of ground contact that must be compensated for by increased muscular activity. The barefoot shoe had the smallest influence, likely due to the minimal loss of foot/ankle motion and minimal proprioception loss.
A type of footwear that is popular but was not included in the study is the high heeled variety. Studies have shown how wearing heels can alter an individual’s gait, which can increase stress on the knees, hips, and spine. One study that included women between 18 and 79 years of age found that the more years of experience one has wearing heels, the more likely they were to experience mid-back pain, and participants who seldom wore heels were more likely to have foot, leg, and low back pain.
The current research suggests that a minimal or barefoot shoe may be optimal for achieving a more natural, hip-friendly gait. However, for individuals who would prefer a more traditional shoe, a low-profile, flexible sole may be the best fit. Of course, if musculoskeletal pain is keeping you from living a more active lifestyle, contact your doctor of chiropractic and schedule an appointment.
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