Monthly Pain Update – February 2023

Management Strategies for Jaw Pain

Temporomandibular disorders (TMDs) are a common condition characterized by pain and discomfort while chewing, which is estimated to affect about 10% of adults to some degree. As with many musculoskeletal conditions that come on gradually and don’t require emergency care, treatment guidelines recommend conservative care as an initial treatment approach, of which doctors of chiropractic are well-equipped to provide.

Following an examination to determine potential causes for the patient’s TMD symptoms, a chiropractor will likely use a combination of manual therapy and specific exercise to restore normal movement to the temporomandibular joint and its relationship with the masticatory muscles. The patient may also be referred to their dentist for an occlusal splint that can be worn overnight to help address abnormal biomechanical loading on the temporomandibular joint. While research supports the short-term effectiveness of occlusal splint use, some studies suggest there may be limited long-term benefits.

In addition to these treatments that are focused on the jaw itself, there’s a growing body of research linking TMD to issues affecting the cervical spine. In a 2021 study that included 60 TMD patients, researchers observed that most participants had moderate-to-severe impairments in cervical mobility, and there was a clear association between neck disability and TMD symptom severity. A 2020 study that included 116 TMD patients arrived at a similar finding. Finally, a 2019 study that analyzed data from South Korea’s National Health Insurance Review and Assessment database found that 48% of TMD patients also have spinal pain, and the more severe their TMD symptoms, the more likely they had neck or back pain.

The good news is that not only is chiropractic care highly effective for managing musculoskeletal disorders that affect the neck but there are studies showing that treatment applied to the cervical spine can improve TMD symptoms. A 2022 study that included 60 TMD patients found that those treated with cervical spinal manipulation experienced significant improvement in the domains of maximal mouth opening, jaw pain, and neck range of motion. This is similar to a 2020 study that included 50 TMD patients.

If you’re experiencing pain or discomfort while chewing or other TMD symptoms, contact your doctor of chiropractic.

Core Stabilization Exercises for Chronic Low Back Pain

In addition to manual therapies and other treatments provided in a chiropractic office, patients with chronic low back pain are often advised to exercise—specifically the core muscles—as part of the recovery process. Is there a protocol that’s best for engaging the core muscles?

In 2018, researchers recruited 34 chronic low back pain patients and assigned them to one of two treatment groups: conventional physiotherapy lumbar exercises or McGill stabilization exercises. The conventional physiotherapy approach included the following exercises: single and double knee to chest, prone lying with pillow with one leg sliding, cycling in the supine position, and bridging exercises. The patients in the McGill stabilization exercise group performed spine-sparing crunches, side bridges, front planks, and bird dogs. Participants in each group exercised three times a week for six weeks. At the conclusion of treatment, each patient completed assessments to measure any improvements with respect to low back-related pain, disability, and range of motion.

The results revealed that the participants in the McGill stabilization group experienced greater improvement in all three domains (pain, disability, and range of motion), suggesting that this approach may be of greater benefit to the chronic low back pain patient. Let’s take a look how each of these exercises are performed:

• Spine-sparing crunch: Lay on your back with right leg straight and the left knee bent with the left foot planted next to the right knee. Place your hands below the lumbar spine (in the gap between the floor and lower back). Lift the head and chest just off the floor/bed and tighten the abdominals. Hold for 3-10 seconds for 3-10 reps and then switch sides. Do three sets.
• Side-Bridge: Lay on your right side and place your right elbow directly under the right shoulder (use a pad under the elbow for comfort) and raise your pelvis up off the floor. Hold for 3-10 seconds for 3-10 reps and then switch sides. Do three sets.
• Front-Plank: Lay on your stomach resting your forearms under your chest and raise your pelvis up (a push-up-like position) tightening the core muscles. Hold for 3-10 seconds for 3-10 reps. Do three sets.
• Bird Dogs: Kneel on all fours (hands and knees/legs) and raise and straighten out the right arm and left leg, bracing your abdominal muscles. Hold for 3-10 seconds for 3-10 reps and then switch sides. Do three sets.

In the end, your doctor of chiropractic knows your specific case and can tailor an exercise protocol to help you get the best possible results, not only to assist in the recovery process but also reduce the risk for recurrence.

Eccentric Strength Training for Tennis Elbow

Lateral epicondylitis—also known as tennis elbow—is a tendinopathy of the extensor forearm muscles, which are located on the back of the hand side of the forearm. It’s estimated the condition affects up to 3% of middle-aged adults. As with many musculoskeletal conditions, treatment guidelines emphasize exhausting non-surgical options before consulting with a surgeon.

In a 2022 systematic review that included 19 studies, researchers concluded that manual therapies and eccentric strength training offered the most favorable cost-to-benefit ratio for the lateral epicondylitis patient. The term eccentric means muscle elongation (the muscle lengthens/elongates during the exercise), which is the opposite of concentric, which means muscle contraction (the muscle shortens/contracts during the exercise). In the context of a bicep curl, the eccentric phase of the exercise occurs when you slowly lower the weight.

Let’s take a look at one eccentric strength training exercise your doctor may recommend in addition to manual therapies applied in a clinical setting.

Begin by resting your forearm on a narrow table or your thigh, grasping a small weight and have your palm facing downward. Use the opposite hand to lift the weight-bearing hand upward. Then, slowly lower the weight to its staring position, resisting gravity as much as possible. Start with a light weight, no more than 2-3 lbs. (.9-1.36 kg) gradually increasing repetitions, sets, and weight over time.  Stay within reasonable pain boundaries and stop if you feel a sharp pain.

It’s also recommended to stretch the extensor forearm muscles several times a day by holding your arm straight in front of you, palm down, with your fingers and wrist limp. Use the other hand to bend the wrist downward until you feel a good stretch in the extensor forearm muscles. Hold for 30-45 seconds for three sets, resting 15-30 seconds between sets. This stretch can also be accomplished by pushing the back of the hand against a wall.

Your doctor of chiropractic can demonstrate these and other exercises that you can perform at home between visits to not only relieve your present tennis elbow symptoms but also reduce the risk of a future episode.

Surgical Vs. Non-Surgical Care for Rotator Cuff Tears

The shoulder is a complex structure that consists of four joints that work together to allow for a large range of motion. Unfortunately, this flexibility results in instability and an elevated risk for injury. Perhaps the well-known shoulder injury is a rotator cuff tear, which will affect at least one-in-five persons during their lifetime. While some patients can recall a specific event that led to their injury, most rotator cuff tears occur over time and may even be present in the absence of symptoms. So, should an individual with a rotator cuff tear consult with a surgeon or explore non-surgical approaches first?

In a 2019 systematic review and meta-analysis that included 57 studies, researchers looked at the natural history of full-thickness rotator cuff tears that were treated surgically or non-surgically and found that both approaches led to similar improvements at three, six, and twelve months. In another systematic review that included ten studies, the investigators found that both surgery and non-surgical treatment provided similar outcomes with respect to range of motion, muscle strength, and quality of life. In yet another study, researchers observed that patients who delayed surgery for six months had better outcomes six-months post-op, leading the authors to suggest using that time to explore non-surgical options.

While the current research supports non-surgical treatments as an initial approach for rotator cuff tears, is it possible to know in advance which patients might experience slower improvement or not respond to care at all? In a 2021 study, researchers monitored 59 rotator cuff tear patients for two years following a course of conservative care and found that all patients experienced better outcomes at the one- and two-year time points; however, the data show that those with symptoms for longer than one year before seeking care, smokers, and those with significant fatty infiltration into the subscapularis muscle may experience slower improvement.

The bottom line is that outside of emergency necessity, patients with a rotator cuff tear should pursue non-surgical treatment as their first option, which includes chiropractic care. Doctors of chiropractic often use a multimodal approach that may include manual therapies, physiotherapy modalities, specific exercises, and nutritional recommendations. If necessary, they can co-manage a patient with their family doctor or a specialist.

The Best & Worst Treatment Choices for Whiplash

Whiplash associated disorders (WAD) encompass a cluster of symptoms—dizziness, mental fog, fatigue, difficulty concentrating and/or comprehending, light/noise sensitivity, memory loss, nervousness/irritability, sleep disturbance, anxiety/depression, and more—that result from a sudden acceleration and deceleration that injures the soft tissues of the head and neck. While each case is unique and can require a tailored treatment plan to give the patient the best chance at a positive outcome, there is research to support that two choices are among the worst and one choice may be the best for WAD treatment.

Worst Choice #1 – Doing nothing, especially in the presence of immediate symptoms (including concussive symptoms). Not only can delaying treatment lead to needless suffering, but it may prolong the recovery process and even increase the risk for chronic WAD.

Worst Choice #2 – Indiscriminate soft cervical collar use. While the concept of immobilizing the neck for a prolonged time frame to allow the soft tissues to heal makes sense, studies have shown that this practice can be detrimental to the patient. For example, cervical collar overuse can decondition the deep neck muscles that stabilize the cervical spine. When the collar is no longer in use, the deep neck muscles can no longer fulfill their duty and the body will recruit the superficial neck muscles to help maintain cervical posture, causing them to fatigue and increasing the risk for additional problems. One study found that WAD patients sent home from the emergency room (ER) with a cervical collar were about 3.5 times more likely to be back in the ER within three months.

Best Choice #1 – Multimodal, conservative care. A systematic review of 1,616 previously published studies looked to find out which interventions or treatments were most cost-effective for managing WAD. The researchers found the favorable approach WAD management includes a combination of manual therapies (such as spinal manipulative therapy and other forms of hands-on treatment provided by doctors of chiropractic), neck-specific exercises, and patient education.

If you experience a sports collision, slip and fall, or auto accident that doesn’t result in immediate issues that require emergency care, try to maintain your usual activities as best you can, and if you experience pain or other WAD-related symptoms, contact your doctor of chiropractic for an evaluation.

Chiropractic and Mental Health Coordination of Care

While musculoskeletal conditions that affect the body are often thought of in terms of pain and disability, it’s not uncommon for psychological factors to be present, which can complicate matters and prolong the patient’s suffering. For example, in a 2019 study that included 252 patients with chronic low back pain, researchers observed that those with psychological factors (mental distress) not only experienced more painful days over the course of the year, but also required more doctor visits.

In an effort to help doctors of chiropractic and other healthcare professionals determine when a referral to a mental health professional is advisable, experts have reviewed the relevant research involving musculoskeletal disorders with co-occurring psychological issues to uncover “yellow flags” that could prolong recovery. These factors can include:

• Fear-avoidance behavior— Unnecessarily restricting movement has been shown to prolong pain and disability.
• Catastrophizing — The tendency of a patient to describe their pain in more negative and exaggerated terms due to a poor understanding of their condition or disease.
• Poor coping skills — The patient seeks to ignore their pain, reinterpret their pain as something else, and divert attention away from their pain rather than engaging in proactive strategies to manage their pain and recovery.
• Mood disorders — Research has shown that depression, anxiety, and other mental health disorders increase the risk of chronicity.

To illustrate how this can play out, a 2022 study looked at the health histories of three spinal pain patients in the Veterans Affairs healthcare system with co-occurring mental health conditions (depression, anxiety, and/or suicide ideation). Following a referral for care that included cognitive behavioral therapy, mindfulness therapy, and/or psychiatric treatment, each patient experienced greater improvements with respect to both pain and function. The authors of the study also note that chiropractic offers an excellent frontline, guideline-recommended treatment approach, highlighting that patients are significantly less likely to receive a subsequent prescription for opioids and other serious medications that can lead to poor long-term outcomes.

If you are struggling with chronic musculoskeletal pain and it’s affecting your quality of life, don’t be afraid or embarrassed to share this information with your doctor of chiropractic as coordinated care with an allied healthcare professional may be necessary to provide the best possible treatment result in the shortest period of time with the least suffering in the interim.

 

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.