Monthly Pain Update – January 2023
Whiplash-Related Dysphagia
The rapid acceleration/deceleration of the head and neck that occurs during a whiplash event can injure the various soft tissues of the head and neck, leading to a cluster of symptoms referred to as whiplash associated disorders (WAD). While features of WAD like neck pain and headache are well known, there are other symptoms that are often overlooked, including problems with swallowing or dysphagia.
The current literature suggests that one-in-ten chronic WAD patients experience dysphagia. While there are several potential causes for difficulty swallowing from abnormal tongue tension to impaired function of the trigeminal and hypoglossal cranial nerves, one study found that the culprit may be the oropharynx, which rests between the soft palate and hyoid bone.
In the study, researchers reviewed MRIs taken of 79 chronic WAD patients and 34 healthy controls. Investigators observed profound structural changes in the size and shape of the oropharynx in the chronic WAD patients. Additionally, the researchers noted that the greater the change in the oropharynx, the higher the levels of bodily pain and stress the patient experienced. The research team added that molecular models of stress-related muscular tensioning could be a potential driver behind WAD-related dysphagia.
The good news is that several studies support that strengthening the muscles in the front of the neck with chin tuck against resistance exercises as one way to manage dysphagia. One way to perform a chin tuck against resistance exercise is to sit up straight with the shoulders back and the chin retracted. Place an inflatable ball between the chin/lower jaw and sternum/upper breastbone. Push the chin with maximum effort into the ball and hold it for 10-30 seconds for three sets with a minute rest between sets. If you feel neck pain, talk to your chiropractor about your starting position as you may not be tucking in the chin properly.
If you’ve been in an auto accident, sports collision, or had a slip and fall and are experiencing whiplash-related symptoms from neck pain to headaches to even difficulty swallowing, schedule an appointment with your doctor of chiropractic to see if chiropractic care can benefit your condition.
Dizziness and the Upper Cervical Spine
Dizziness affects about 15-20% of adults to some extent each year, and it is one of the most common reasons for emergency room visits. One of the three systems that works to help us maintain balance is the proprioceptive system that is made up of mechano-receptors located in our joint capsules, muscles, and more that communicate with the brain to let it know where each part of the body is in space. This sensory input comes from all over the body and through the upper neck and into the brain.
In the presence of a musculoskeletal disorder that affects the upper cervical spine, the sensory input that feeds the proprioceptive system can become altered or disturbed, which is experienced as dizziness. Patients with dizziness caused by dysfunction in the neck—called cervicogenic dizziness—often describe their symptoms as “drunklike” or lightheaded feelings, dizziness associated with neck movements, restricted neck motion, and neck pain.
The GOOD NEWS is that manual therapies—the primary treatment utilized by chiropractors—have been shown to significantly benefit cervicogenic dizziness patients. In a 2022 randomized-controlled trial that included 40 cervicogenic headache patients, researchers divided patients into two groups. The first group received three treatments 48 hours apart that included upper cervical soft-tissue therapy followed by high-velocity, low amplitude thrust manipulation. The other group received no treatment and served as a control group.
The researchers observed that the patients in the treatment group not only experienced greater improvements in pain intensity, spinal mobility, and dizziness after the treatment phase of the study, but these benefits persisted up to a month later during a follow-up visit. The patients in the control group reported no improvement at either time point.
The findings suggest that patients experiencing dizziness that’s accompanied by restricted cervical range or motion or neck pain should be evaluated by a doctor of chiropractic to determine if they can benefit from treatment to restore normal motion to the upper cervical spine.
Motor Control, Spinal Stability, and Low Back Pain
In a chiropractor’s ideal world, people would do everything possible to reduce their risk for a condition like low back pain, and in the event a low back injury occurs, they’d seek care right away. Barring any red flags that necessitate a referral to a specialist or a trip to the emergency room, the patient would receive care tailored to their unique situation and soon be back to carrying out their everyday activities. Unfortunately, this is rarely the case, and a patient with low back pain may receive no care or inadequate treatment early on, and their condition may progress to becoming chronic low back pain before they make an appointment with a local chiropractic clinic.
A hallmark of chronic low back pain that can complicate recovery is clinical instability or dysfunction in one of the three subsystems that work together to maintain the stability of the spine: the spinal column, the spinal muscles, and the neural control unit. This can lead to excessive movement of one or more spinal segments, overworking and stressing the surrounding muscles, joints, and other soft tissues, causing inflammation and nociceptive (localized) pain.
The key for muscle stabilization in the lumbar spine, which accounts for 60% of the spine’s stiffness, is the multifidus muscle. Unlike superficial muscles that contract to achieve movement, deep muscles like the multifidus work to help maintain posture. Unfortunately, when the lower back is injured, the superficial muscles take on a protective role, which can interfere with the role of the deep muscles. Within days, the multifidus muscle can weaken, and to maintain stability, the body will recruit the superficial muscles and/or adopt new movement patterns, both of which can increase mechanical stress in the low back and elsewhere and prolong or worsen the patients’ condition. This is why treatment guidelines no longer recommend prolonged bed rest for low back pain but rather maintaining usual activities as much as possible.
When a patient seeks chiropractic care for chronic low back pain, not only will treatment focus on restoring normal motion to the spine using manual therapies (like spinal manipulation) but also core strengthening exercises that can be performed at home to strengthen the core muscles (including the multifidus) and increase the stability of the spine. This strategy will not only speed up recovery but help reduce the risk for a future low back episode.
The Patient Experience with Carpal Tunnel Syndrome
When it comes to a condition like carpal tunnel syndrome (CTS), we often look at it from the standpoint of risk factors, potential causes, and treatment options. However, there’s a perspective that’s often overlooked: the experience of the patient as they navigate the process from diagnosis to treatment outcomes. In a 2022 study, researchers conducted in-depth interviews with eighteen female patients with CTS and identified four main themes:
Delayed treatment and slow diagnosis: The women noted that they delayed seeking treatment in hopes their pain and other symptoms would go away. Once they sought care, they found the testing process to be slow, especially if it included referral to a specialist, like a neurologist. One patient was told the diagnosis wasn’t clear, which left her confused and unhappy.
Non-surgical options: Once the diagnosis was made, the only treatment offered to those with severe CTS was surgery. In less severe cases, participants utilized conservative treatments including night splints, medication, injections, stretching, and physiotherapy. Both primary care physicians and specialists recommended nocturnal splinting; however, several of the patients had already tried wearing a splint at night on the recommendation of a friend, co-worker, or pharmacist before they scheduled their initial consultation.
Desire to avoid surgery: Regarding surgery—although it was the most frequent option offered by specialist physicians—many of the interviewees rejected it because they did not receive assurance their hand/wrist would function properly after surgery or that it would yield a complete resolution and they wouldn’t need additional surgeries.
Clinician conflicts: Several of the women reported conflicts with their doctor with complaints including failure to listen to their needs or questions, limiting treatment choices to either accepting or rejecting surgery, not offering non-surgical options, and inadequate time to discuss their situation.
Of note, a systematic review that was also published in 2022 on the patient-chiropractor relationship included 30 studies and found that both doctors of chiropractic and patients consider a strong working alliance as a key factor in the treatment journey!
The Various Causes of Patellofemoral Knee Pain
In addition to being the largest joint in the body, the knee is also very complex and consists of several components that all work together to help us stand, walk, run, jump, and climb. The patella, or kneecap, is located in the front of the joint at the distal end of the femur and rides up and down in the femoral groove (trochlea) when we flex and extend our knee. Patellofemoral pain syndrome (PFPS) is a very common musculoskeletal condition, especially among athletes where it’s known as runner’s knee or jumper’s knee.
Patellofemoral pain syndrome can arise from many sources including a strain of the quadriceps tendon that connects the muscle to the upper pole of the patella (quadriceps tendinitis); arthritis affecting the articular cartilage; and strain of the quadriceps tendon that connects the bottom of the patella to the top front of the tibia to a bump called the tibial tuberosity (patellar tendonitis). When evaluating a patient with patellofemoral knee pain, a doctor of chiropractic will evaluate the laxity of the knee joint, knee extensor strength, alignment of the lower extremity, and coordination of the medial and lateral quadriceps muscle groups.
Additionally, the chiropractor will examine the hip, lumbosacral, and sacroiliac regions because dysfunction in these body sites can contribute to issues affecting the knee, which is supported by a May 2021 study in which researchers divided 43 PFPS patients into two groups. The first group received six weekly sessions that included supervised knee and hip muscle exercise with mobilization of the patellofemoral joint and the other group received six weekly treatments that included high-velocity, low-amplitude thrust manipulation directed at the thoracolumbar region, sacroiliac joint, and/or hip. Both groups performed knee-specific home exercises during the treatment period. At the conclusion of care, the patients in the thrust manipulation group exhibited greater improvements with respect to knee pain and function, and these benefits persisted during a follow-up evaluation six weeks later.
Because PFPS can have multiple contributing causes, the treatment plan presented to the patient will be tailored to their unique case. The plan may include manual therapies, taping, bracing, orthotics, exercises, dry needling, acupuncture, and modalities like ultrasound, electrical stimulation, laser, pulsed magnetic field, and more.
The Crura of the Diaphragm and GERD
Gastroesophageal reflux disease (GERD) is a condition that occurs when the contents from the stomach reflux back up into the esophagus—the tube that transfers food and drink from the mouth to the acidic environment of the stomach-leading to a foul burning taste in the throat and the chest pain known as heart burn. Standard treatment options include lifestyle modifications or the use of proton pump inhibitors (PPI). For the calcitrant (non-responders), a medical specialist may recommend surgery to tighten up the hiatus—or opening in the diaphragm through which the esophagus travels prior to connecting with the stomach. Due to the significant side-effects associated with long-term PPI use and a desire to avoid surgery, many patients may seek an alternative approach to manage GERD based on either their own research or at the recommendation of their treating doctor.
In recent years, several studies have focused on the use of manual therapies and other conservative approaches to strengthen the muscles associated with the esophagus to prevent reflux of acids from the stomach. One study demonstrated the benefit of specific respiratory exercises aimed at strengthening the crura of the diaphragm. The authors reported that this simple exercise increased the patients’ quality of life, decreased the GERD-related symptoms, and reduced their PPI use. The authors hypothesized that the crura of the diaphragm is a key component of the anti-reflux barrier because it functions as an extrinsic esophagogastric junction sphincter (valve). Another study that included 60 GERD patients found that visceral manipulation technique to improve function in this region also led to improvements in GERD-related symptoms, PPI use, and quality of life.
A more recent 30-patient randomized controlled trial evaluated the efficacy of myofascial release—a manual therapy performed by applying three-dimensional low-load pressures to the fascial tissue over extended periods with the goal of pain reduction and function improvement—in improving GERD symptoms using techniques designed to restore the myofascial properties of the crura of the diaphragm. Participants underwent either four 25-minute myofascial release sessions spread over two weeks or four sham treatments in the same time frame. Those in the myofascial release group reported significant improvements in GERD symptoms, PPI use, and quality of life after both the conclusion of the treatment period and one month later during a follow-up visit. A related study that used high-resolution esophageal manometry showed that myofascial release resulted in an immediate increase in lower esophageal sphincter pressure.
These studies support the fact that there are alternative treatment options for managing GERD without the indefinite use of PPIs or more invasive options. If you’re currently under treatment for GERD with your medical physician, ask them if they’d consider referring you to a doctor of chiropractic for manual therapy treatment to improve the function of the crura of the diaphragm and related tissues to see if it can improve your GERD-related symptoms.
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.
