Monthly Pain Update – December 2022

Mid-Back Pain and Its Causes

The thoracic portion of the spine the longest part of the spine and is made up of twelve vertebrae (T1-T12), which lies between the cervical spine (C1-C7) and the lumbar spine (L1-L5). The thoracic spine protects the very important spinal cord that begins in the brain and runs down to approximately T12 where the cord turns into what looks like a horse’s tail (the cauda equina). The spinal nerves then travel into the lumbar spine and sacrum (tailbone) and innervate the low back, pelvis, legs, and feet. Nerve roots exit at each vertebral level of the spine innervating the upper (cervical), middle (thoracic) and lower (lumbar) portions of the body.

Looking closer at the T1-T12 nerves, T1-T2 nerves innervate (motor/muscle and sensory/feeling) the top of the chest and the inner arms and hands (providing strength to the deep, intrinsic hand muscles). Nerves T3-T5 innervate the chest wall and help control the rib cage, lungs, and diaphragm (the breathing muscle that separates the chest cavity from the abdominal cavity). The T6-T12 nerves innervates the abdominal and back muscles that work with the lumbar nerves to help stabilize our core, balance, posture, and the coughing process.

The thoracic spine also supports the rib cage, which protects our lungs, heart, and its great vessels that supply our body with fresh, oxygenated (arterial) blood and trades off carbon dioxide (venous blood) for oxygen in the lungs each time we take a breath. All of this is done automatically, without effort or thinking, thanks to our autonomic nervous system (ANS— made up of sympathetic and parasympathetic nerves) of which many of the sympathetic nerves arise in the thoracic region!

Unlike the cervical and lumbar portions of the spine, which allow for a great deal of movement, the thoracic spine is much more rigid and stable, which leads to a lower risk for injury. Potential causes of mid-back pain include poor posture; prolonged sitting; or conditions like scoliosis (curvature) or hyper-kyphosis (increased “humping” of the TS); sprain of the ligaments that hold bones firmly together (usually by a sudden, unexpected movements or trauma); bruising, cracking, or fracturing of the ribs or thoracic vertebrae; compression fracturing due to osteoporosis; and overuse injuries from repetitive lifting, bending, and twisting.

Doctors of chiropractic are trained to evaluate and treat patients with MBP utilizing various forms of manual therapies (including spinal manipulation, mobilization, and massage), exercise training, posture retraining, and more.

Help for Chronic Non-Specific Neck Pain Patients

Chronic non-specific neck pain is the most common form of neck pain. While the inclusion of the word “non-specific” implies the cause of neck pain is unknown, the term really describes neck pain without an underlying disease or pathology—like an infection or osteoporotic fracture. Thus, chronic non-specific neck pain is better understood as neck pain arising from postural or mechanical causes of the neck that has persisted for at least three months.

When a patient initially consults with a doctor of chiropractic regarding their chronic neck pain, they’ll complete a healthy history. If any red flags are present that suggest a more serious and potentially life-threatening condition—sudden weight loss, fever, severe pain, loss of coordination, chest pain, shortness of breath, thunderclap headache, etc.—the patient may immediately be referred to the emergency department or a specialist.

The doctor of chiropractic will then perform a physical examination to identify the primary pain generator(s) by using palpation, orthopedic tests, and range of motion (often, limited in one particular direction) while tracing the pain—especially if it radiates into an arm or down into the shoulder blade region. The doctor of chiropractic will also assess the upper extremity nerves for motor (muscle strength and reflexes) and sensory function (skin senses to pin prick, scratch).

Perhaps the most common cause of non-specific neck pain is injury to the facet joints that sit at the rear of the spinal vertebrae. However, the patient’s neck pain may also be caused by the disks, muscles, tendons, and ligaments that are involved in supporting the head and putting the neck through its full range of motion. Patients with chronic neck pain are also likely to have postural defects—such as forward head posture—that place abnormal strain on the tissues of the neck to support the head.

Once the potential pain generators are identified, the doctor of chiropractic will formulate a treatment plan that may include spinal manipulation, mobilization, manual release techniques, trigger point therapy, neck-specific exercises, and postural retraining—all with the goal of reducing neck pain and disability so that the patient can resume their everyday work and life activities.

How Chiropractors Diagnose Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy of the upper extremity. It can arise from many causes (sometimes more than one at the same time) such as anatomical variations, ganglion cysts, occupational mechanical stress, and systemic diseases including obesity, drug toxicity, alcoholism, diabetes, hypothyroid, rheumatoid arthritis (RA), etc. Let’s discuss how a doctor of chiropractic diagnoses CTS.

HISTORY: First, to assess CTS, your chiropractor will gather your history and evaluate in the information using an acronym such as LMNOPQRST which stands for: Location (wrist/hand); Medical history (diabetes, thyroid, RA, etc.); New (symptoms/events—case specific); Onset—when did it start; Provoking/Palliative (what makes it worse/better); Quality (numb, tingly, pain); Radiation— to thumb-half of the hand or, into the forearm; Severity—0-10 for now, average, at best, at worst—(case specific); Timing—better/worse AMs, PMs, during sleep, work, past history. According to an interesting study in the BMJ, the authors cited five references that stated physicians garner 60-80% of the information that is relevant for making a diagnosis through the case history alone.

PHYSICAL EXAM: The purpose of a physical examination is two-fold: 1) to establish the diagnosis (which the history points to); 2) to rule out other neurological or musculoskeletal (MSK) diagnoses. Also, CTS often co-exists with other conditions and/or causations that can lead to carpal tunnel syndrome-like symptoms. Your chiropractor will perform provocative orthopedic tests (POTs) in an attempt to reproduce CTS symptoms. Some common examples of POTs include the Phalen test, the Tinel test, the Hand Elevation Test, and the Durkan test.

DIAGNOSTIC TESTING: X-rays are usually not used to diagnose CTS unless fracture or pathology is suspected. Blood work may be requested to assess for the conditions cited in the opening paragraph. Electrodiagnostic testing, such as neuro-conductive velocity (NCV) testing, may be requested (usually via referral to a neurologist) to assess the speed of nerve transmission, which is usually slower in CTS patients.

Doctors of chiropractic are well-trained at diagnosing AND treating CTS patients with a non-surgical approach, which is the FIRST course of care recommended by all CTS treatment guidelines.

Hip Motion and Low Back Pain

There are many studies that support the theory that kinetic chain dysfunction in the lower extremities—the foot, ankle, knee, or hip injury and/or condition—can alter normal lumbo-pelvic biomechanics, which can lead to low back pain. Let’s take a look at how abnormal motion in the hip can affect the lower back.

A 2015 literature review looked at twelve studies on the correlation between hip rotation range of motion loss and low back pain and concluded that patients with low back pain are likely to exhibit impaired and asymmetrical total hip rotation range of motion (ROM).

Another study that included 40 low back pain patients—also published in 2012—looked at flexion (forward) and extension (backward) hip mobility and how that correlated with limitations in low back flexion and extension. The researchers found that 57.5% of the participants had a considerable loss of either hip flexion or extension, and they also experienced corresponding impairment in low back flexion or extension 78.3% of the time. A quarter of the participants had considerable loss in both hip flexion and extension, and 70% also had considerable loss in both low back flexion and extension. The remainder of participants (17.5%) had minimal loss of hip motion.

So, the first study noted that loss of hip rotation correlates with increased likelihood of having low back pain, and the second study found that patients with low back pain often experience impairments in hip motion that pair with restricted low back movement. To further investigate this intimate hip-low back relationship, the authors of a 2017 study examined 101 middle-aged low back pain patients with or without lower extremity pain and found that 80% of the patients in the study had both hip and low back findings, and these individuals had more intense pain and function loss than the participants without an accompanying hip issue. Hence, the authors conclude that low back pain is worse when hip problems exist.

This relationship isn’t limited to adults in mid- and late-life either. A 2022 study found that low back pain is common in high school tennis players, affecting about 30% in the previous year. A comparison of those with or without a recent history of low back pain revealed an association between restricted hip internal rotation of the non-dominant leg and low back pain.

The findings highlight the importance of examining the whole patient when they present with a condition such as low back pain because it’s common for issues outside of the low back to contribute to the patient’s chief complaint. Fortunately, both low back and hip disorders often respond positively to a multimodal approach used by doctors of chiropractic.

Eye Exercises for the Whiplash Patient

Whiplash associated disorder (WAD) has been known to affect nerve function, which can manifest as several symptoms, including visual problems. If the initial chiropractic examination reveals altered ocular function, the patient’s chiropractor may recommend a variety of eye-specific exercises to aid in the healing process.

• Blinking: When using a screened device, blinking essentially rests the eyes, which reduces eye strain and keeps them lubricated. Not only does this help prevent dry eye, but it can prolong focus. Try blinking for 10 seconds (1 rep/second) every 20 minutes of screen time. Also, focus on a far-off object for 20 seconds every 20 minutes when working at the computer.
• Eye movements: Slowly move your eyes up and down three times; then move them left to right three times and then shut your eyes and rest for 15-30 seconds.
• Figure-8: Imagine a large poster about 8-10 ft away that features two 8s, one upright and one on its side. Starting with the upright 8, move your eyes tracing the path of the 8 for about 30 seconds and reverse the direction. Repeat the same with the sideways 8. Blink/rest as needed. If needed, start with 5-10 seconds and work up to 30 seconds.
• Focus: Hold a finger or sharp pencil a few inches out in front of your eyes (in a well-lit room), and focus on the tip for a few seconds. Then focus on a far-off object until it comes into focus. Return to your finger/pencil and repeat this five-to-ten times, gradually increasing the repetitions (blink/rest as needed).
• Convergence: Holding your thumb or a pencil upward with your outstretched arm, slowly bring the thumb/pencil closer to the bridge of your nose (equally between the eyes) until you see two. Then move it back until only one thumb/pencil reappears. Slowly repeat the loss and gain of one object five-to-ten times, again respecting fatigue and/or other irritating symptoms (light headedness, dizziness, pain, etc.). Be patient and work slowly but purposefully.

Not only can these exercises benefit the WAD patient with ocular dysfunction, but they can also help those with digital eye strain, photophobia (increased sensitivity to light), post-surgical balancing of the ocular muscles, focus problems, convergence insufficiency (inability to cross the eyes), and lazy eye (often seen in kids).

Improving Sleep Quality

In the absence of a sleep disorder, most people take getting a quality night’s sleep for granted, as well as all the health benefits that accompany good sleep hygiene. However, when someone has trouble sleeping through the night, it can be expressed in fatigue, irritability, daytime dysfunction (including increased workplace errors and injuries), slowed responses, and increased caffeine/alcohol intake. Over time, poor sleep quality can even contribute to chronic disease and poor health outcomes. Studies published in the last few years have identified the following way to improve sleep quality:

• Be Consistent: A 2021 study found that having a fixed, consistent sleep schedule with seven to eight hours of uninterrupted, quality sleep each night is associated with a 66% lower risk of high blood pressure, a 58% lower risk of type 2 diabetes, a 73% lower risk of obesity, and a 69% lower risk of having central adiposity.
• Get Regular Exercise: Among a group of 40 middle-aged and older adults with problems getting a good night’s sleep, those who participated in a twelve-week aerobic exercise and stretching program reported significant improvements in sleep quality.
• Avoid Intense Exercise Before Bed: Following a review of data from 15 studies, researchers report that exercising at high intensity within two hours of bedtime may increase the length of time needed to fall asleep as well as reduce sleep duration.
• Turn Music Off Before Bed: A June 2021 study found that the brain may continue to process music listened to prior to sleep, which can negatively affect sleep quality.
• Go to Bed Earlier: A May 2021 study found that going to bed and waking an hour earlier can reduce one’s risk for depression by up to 23%, even though there’s no difference in sleep duration. Additionally, shifting sleep/wake times forward by two hours can lower the risk for depression by nearly 40%.
• Sleep with a Pet: A study that included 188 children aged 11 to 17 found that those who shared a bed with a pet were more likely to report high subjective sleep quality.
• Try a Weighted Blanket: Among a group of twelve adults who had been previously diagnosed with clinical insomnia and a co-occurring psychiatric disorder, researchers found that sleeping with a weighted blanket resulted in both improved sleep quality and a reduction in anxiety and depression symptoms.
• Eat Better: Young women with a low fruit and vegetable intake (fewer than three servings a day) who doubled their produce consumption experienced improvements in sleep quality. Likewise, a review of findings from 29 studies concluded that a high intake of sugar-added and processed foods is associated with an increased risk for poor sleep. The researchers also cited evidence that a healthy diet pattern may be linked with better sleep quality.

Lastly, visit your doctor of chiropractic. Past research has established a bi-directional relationship between low back pain and poor sleep. That is, having one makes the other more likely. Additionally, an analysis of 32 studies, which included over 10,000 people, found that individuals with chronic migraines are not only more likely to experience poor sleep quality but they also spend less time in rapid eye movement (REM) sleep, which is the phase of sleep associated with dreaming. So if you have musculoskeletal pain and trouble sleeping, then managing your pain via chiropractic care might also help you sleep better.

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.