Monthly Pain Update – October 2023
The Thoracolumbar Fascia and Chronic Low Back Pain
The thoracolumbar fascia is a structure in the lower back that is comprised of layers of densely packed collagen and elastic fibers separated by loose connective tissue that allow the deep stabilizing muscles in the lower back to move independently of the superficial muscles used for twisting and bending forward and backward. When adhesions form in the fascia, movement can become restricted, which can lead to pain and disability in the lower back and nearby parts of the body. A January 2023 study that included 131 adults—68 with low back pain—revealed a 25-30% reduction in thoracolumbar fascia elasticity among those with low back pain. This suggests that improving the function of the thoracolumbar fascia is essential in the management of low back pain. So, what can your doctor of chiropractor do to improve the elasticity of these important tissues?
The most common technique used to address adhesions in the thoracolumbar fascia is a manual therapy technique called myofascial therapy or myofascial release. Myofascial release is a hands-on treatment in which a doctor of chiropractic applies pressure with their hands, elbow, or a tool to stretch the muscles to knead out trigger points or adhesions that may inhibit the ability of the muscles to slide against one another during normal movements. In the last thirty years, various forms of myofascial therapy have been developed and disseminated to healthcare professionals who apply hands-on care, which includes doctors of chiropractic. In addition to care provided in the office, patients may also be instructed on self-myofascial release, which may include the use of a foam roller, for example.
In 2021, two systematic reviews—studies that pool data from previously published studies— concluded that myofascial therapy is effective for reducing disability and pain in patients with low back pain. More recently, a 2023 study that included 48 patients with low back pain found that those treated with a single session of myofascial therapy experienced a significant decrease in pain and thickness of the thoracolumbar fascia, in addition to a reduction in stiffness in the erector spinae muscles and thoracolumbar fascia. Follow-up examinations after the treatment showed the benefits persisted two and seven days later.
In many cases, there are many contributing factors to a patient’s low back pain that must all be addressed to achieve a satisfactory result. This starts with a thorough examination to understand the patient’s unique situation and extends to a multimodal approach that incorporates several treatment methods to reduce pain and improve mobility in the lower back, which can include myofascial treatment to break down adhesions in the thoracolumbar fascia to allow for proper movement. In fact, an October 2022 study found that a multimodal chiropractic treatment plan that included spinal manipulation, education, exercise, self-management advice, and myofascial therapies led to improvements in pain, disability, and thoracolumbar fascia mobility in women with chronic low back pain.
Neck Disorders and Their Connection to Migraines
It’s estimated that about 38 million American adults suffer from migraines and nine-in-ten report that to some degree, migraines affect their ability to carry out their normal social, leisure, work, and everyday activities. Unfortunately, there isn’t a one-size-fits-all treatment for migraines as the condition is not well understood and management tends to focus on lifestyle modifications to avoid potential triggers for a patient’s particular migraine profile. But what if a potential key to managing migraines wasn’t in the head at all? What if the neck had a role to play in migraine headaches?
A 2015 study found that 87% of chronic migraine headache patients also have neck pain.
Compared with the non-headache sufferers the researchers questioned, individuals with migraines were roughly three-to-four times more likely to have neck pain. To highlight this relationship between the neck and migraines, a 2023 study looked at 295 migraine patients and found that more than half (51.9%) also had concurrent neck pain. Further analysis showed that migraine sufferers with concurrent neck pain reported more severe migraine symptoms, and the more disabling their neck pain, the worse their migraines. This makes some sense as the trigeminal nerve, which helps innervate the face and has been linked to migraines, exits the spinal cord through the upper cervical spine and travels into the face. In addition to irritation of the trigeminal nerve having a part to play in the migraine process, previous studies have identified a link between migraines and impaired cervical range of motion, reduced neck muscle endurance, and the presence of trigger points in the neck muscles.
The good news is that doctors of chiropractic have a number of tools in their treatment repertoire for addressing these issues: spinal manipulation, mobilization, myofascial release, and other manual therapies to dry needling, neck-specific exercise, postural training, dietary recommendations, and more. It all depends on the patient’s unique presentation. This approach appears to be effective, as demonstrated in a recent three-armed trial that compared spinal manipulative therapy, sham manual treatment, and usual medical care after a three-month treatment period with follow-ups at three, six, and twelve months. The results favored chiropractic care at all time points. A systematic review of 13 studies published in 2022 concluded that mobilization techniques, trigger point therapy, manual lymphatic drainage, massage, and stretching techniques are each effective interventions for migraine headache patients, especially when used in combination.
Other studies have demonstrated that addressing trigger points in the neck and other disorders in the
cervical spine can result in reduced frequency, intensity, and duration of migraine episodes. While managing migraines may require a comprehensive approach that includes exercise, diet, and lifestyle modifications, it’s clear that disorders of the neck can contribute to, if not be an underlying cause of, migraines and should be addressed. If you suffer from migraines, especially if you also have neck pain or stiffness, consult your doctor of chiropractic.
What Is Tennis Leg?
The term tennis elbow is widely known because it’s a common malady associated with tennis (and more recently, pickleball), primarily due to the use of a back-hand stroke. For those who play racquet sports, there’s another common orthopedic condition that includes the word tennis: tennis leg.
The condition is characterized by a popping noise in the calf during a movement associated with the leg pushing off during a jump, sprint, or sudden change of direction followed by a sharp, burning sensation that makes it difficult to bear weight on the leg. Though it may not initially be observed, tennis leg can lead to superficial bruising, swelling, limitations in knee and ankle range of motion, and increased calf pain at the end-range of ankle dorsiflexion (bringing the toes toward the nose) and with manual palpation. It’s important to note that like tennis elbow, tennis leg is not just a sport-related injury but can also occur in non-athletes.
If you hadn’t heard the term before, you may be surprised to discover it was first clinically described way back in 1883! The condition was initially attributed to rupture of the plantaris muscle tendon in the calf region of the lower leg. However, more recent studies using ultrasound and MRI have shown that in nearly all cases, tennis leg is the result of injury to the gastrocnemius and/or soleus muscles in the calf. In one study, researchers evaluated MRIs of 58 patients with tennis leg and observed that edema or disruption of the medial head of the gastrocnemius at the muscle-tendon junction in 55
cases (90.2%); fluid collection between the medial head of the gastrocnemius and soleus in 44 cases (72.1%); injury to the soleus muscle (which is deeper to the gastrocnemius) in 22 (36.1%) of the cases; and plantaris muscle disruption in 7 cases (11.5%). In rare cases, tennis leg may be due to deep venous thrombosis posing as a muscle injury, which may require prompt medical attention.
Treatment generally follows the PRICE (Protect, Rest, Ice, Compress, Elevate) protocol and may include the use of a boot, modalities to reduce inflammation and promote healing (like laser or pulsed magnetic field), passive range of ankle/knee motion within pain boundaries, and manual therapies to address any musculoskeletal disorders in adjacent parts of the body that may have preceded and contributed to the injury.
Carpal Tunnel Syndrome and Regional Interdependence
Carpal tunnel syndrome (CTS) is the most common compression neuropathy of the upper extremity, which is caused by increased pressure on the median nerve as it passes through the wrist with resulting symptoms of pain, numbness, and tingling in the thumb through third finger and thumb half of the fourth finger (palm-side). Traditionally, treatment guidelines for CTS have focused on therapies applied to the wrist. However, there is a growing understanding in the research community that CTS may be best viewed as a complex pain syndrome that requires a comprehensive sensory nervous system approach to achieve a satisfactory outcome for the patient.
Current literature suggests that 45% of CTS patients may also experience pain in the forearm, elbow, and shoulder and 14% have concurrent neck pain. Patients with CTS have also been observed to have myofascial trigger points in upper trapezius and infraspinatus muscles, as well as osteoarthritis in the cervical spine. Carpal tunnel syndrome sufferers may also have reduced cervical range of motion to the side opposite the affected wrist in addition to forward head posture—which occurs when the head rests forward of the sagittal plane, placing added stress on the soft tissues at the back of the neck and upper back to keep the head upright. Because these issues can occur along the course of the median nerve or affect anatomical regions that the median nerve passes through, treatment to address these disorders can reduce a patient’s CTS symptoms. The term “regional interdependence” is used when interventions applied to one anatomical region can influence the outcome and function of other body regions that may be seemingly unrelated.
In a June 2023 pilot study that included 15 CTS patients, researchers observed that a treatment plan consisting of ten sessions of manual traction, lateral glide mobilization, and posterior to anterior pressure applied to the neck, along with self-stretching of the upper fibers of the trapezius, scalenes, and levator scapulae muscles led to improvements in CTS pain intensity, symptoms severity, disability, and functional capacity, as well as improved function of the median nerve based on electrodiagnostic studies of median nerve motor distal latency and medial sensory nerve conduction velocity. Best of all, these improvements persisted when researchers examined the patents six months after the conclusion of care.
For decades, doctors of chiropractic have focused on the full course of the median nerve when assessing a patient with carpal tunnel syndrome symptoms based on their experience that compression of the median nerve beyond the wrist can contribute to CTS. It’s great to see that the scientific community is starting catch up and look at CTS as not just an issue of the wrist itself but more of a disorder that can include multiple body sites that all need treatment to get a patient out of pain and back to their normal activities.
Cervical Spinal Stenosis and Whiplash Injury
Cervical spinal stenosis (CSS) is a condition characterized by the narrowing of the spaces within the spine through which the spinal cord and the nerves pass. The condition becomes more common with age, affecting 6.8% of adults over age 50 and 9% of those over age 70. While it’s not unusual for a CSS patient to be asymptomatic, a sudden injury to neck tissues can compress, constrict, or injure the spinal cord (or associated nerves) and result in symptoms such as pain, numbness, and/or tingling along the course of that nerve that can affect physical function over time.
It’s estimated that more than two million Americans sustain a whiplash injury each year, with automobile collisions being the primary cause. In a June 2023 study, researchers used a previously validated three-dimensional model of the human head-neck complex to assess the risk for spinal cord injury with CSS of varying sizes (from 14 mm to 6 mm—a lower number is worse) with rear-impact acceleration of both 1.8 m/s and 2.6 m/s. At the C5-6 level of the cervical spine, which sits toward the bottom of the neck, the stress on the spinal cord was enough to cause injury at both accelerations with a stenosis of 6 mm. However, for the less severe 8 mm stenosis, only 2.6 m/s acceleration applied sufficient forces to injure the spinal cord. In general, the authors surmised that the narrower the opening for the nerve/spinal cord to pass through, the less force needed to reach the threshold for spinal cord injury.
Aside from genetics, the risk factors for CSS include cumulative trauma, osteoporosis, cigarette smoking, and degenerative joint disease/osteoarthritis—all of which can affect the ability of the tissues of the neck to absorb the forces stemming from the sudden acceleration and deceleration during a rear-end collision, leading to a potentially more severe injury, which may require a more comprehensive treatment approach to reduce the risk for ongoing, chronic symptoms. The good news is that doctors of chiropractic offer an excellent conservative treatment option for managing both cervical spinal stenosis and whiplash injuries.
While it may not be possible to fully prevent CSS, there are measures one can take to reduce their risk for developing the condition. This includes eating a healthy diet, getting regular weight-bearing exercise, getting good sleep, not smoking, avoiding excessive alcohol intake, and avoiding the risk factors for metabolic syndrome including obesity, hypertension, diabetes, and dyslipidemia. A 2018 study found a link between worse spinal posture and spinal stenosis, so maintaining good posture and getting regular chiropractic care to keep the spine aligned may also lower the risk for CSS!
Royal Jelly and Stronger Bones
Royal jelly is a milk–like secretion of honeybees that is used to feed the larvae in the honeycomb to facilitate development into drones (males), worker bees (infertile females), and queens (fertile females). The National Institutes of Health notes that royal jelly consists of water, proteins, amino acids, fatty acids, simple carbohydrates, vitamins, and minerals and the active ingredient that stimulates and modulates larval development is believed to be a series of major royal jelly proteins (MRJP). The substance is harvested from the individual queen bee cells from beehives and is made into topical creams as well as dietary supplements.
Many people believe royal jelly offers several health-enhancing benefits from slowing the aging process to enhancing the immune system to improving conditions such as diabetes, high cholesterol, asthma, fatigue, hay fever, kidney disease, pancreatitis, PMS, and more. Such claims are not sufficiently substantiated in the literature for firm recommendations to be made. However, as more research is conducted, royal jelly may begin to be recommended in a healthcare setting for one or more conditions. One area that looks promising is the effect royal jelly may have on bone health.
Osteoporosis is characterized by the depletion of bone mineral mass combined with bone micro-architecture deterioration that results in greater bone fragility leading to increased fracture risk. It’s reported that just a 10% reduction in vertebral bone density can double the risk for fracture. It’s estimated that 10 million adults in the United States have osteoporosis and another 44 million are at serious risk for the condition, thus the importance of identifying strategies to preserve bone mass as people age.
In a 2021 study, researchers studied the effects of royal jelly protein supplementation on female rats at risk for osteoporosis. After eight weeks, the equivalent of roughly five years of human life, the rats given a royal jelly protein supplement had greater lumbar spine, tibia, and femur bone mineral density and strength than subjects not given the supplement. The authors of the study note that further research is needed to understand the physiological mechanisms behind bone loss suppression associated with royal jelly protein intake.
If future research supports the benefits of royal jelly protein for preserving bone mass in humans, we may find it being added to lifestyle recommendations for aging adults at risk for osteoporosis such as maintaining a healthy vitamin D status, taking a calcium supplement, eating a healthy diet pattern (like the Mediterranean diet), and engaging in regular weight-bearing exercise.
Chad Abramson, D.C.
12720 4th Ave W #F324
Everett, WA 98204 (425) 315-6262
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.
