Monthly Pain Update – November 2023
Posture and Neck Pain in the Younger Population
After low back pain, neck pain is the most common reason for a visit to a chiropractic office. There are many risk factors for neck pain including postural faults in the neck and upper torso. Let’s look at how common poor posture is among youths and what can be done to reduce the risk for neck pain in children and teens both inside and outside of the doctor’s office.
Upper crossed syndrome (UCS) is a postural fault characterized by a weakness of the deep neck flexors and interscapular (middle and lower trapezius) muscles and over-tightness/shortness of the upper back and neck and pectoralis (chest) musculature forming an “X” when looking at the body from the side and connecting the weak muscles and tight muscles with imaginary lines. This can cause the head and shoulders to rest forward of their normal position, straining the soft tissues of the neck and upper back, which can manifest as neck pain.
In a January 2023 study, researchers examined secondary school students and observed that 37.8% exhibited UCS, 38.9% had forward head posture, and 80% had forward shoulder posture. Further analysis revealed that students who were overweight, physically inactive, wore a heavy backpack, and spent too much time on electronic devices were at greater risk for poor posture. Additionally, the data show that UCS is associated with worse academic performance!
The good news is that a randomized controlled study that included adolescents from two schools found that those who participated in a 16-week resistance and stretching program incorporated into their standard gym class led to measurable improvements in neck and shoulder posture. The program in the study included chin and scapular retractions; stretching of the pectoralis, levator scapulae, and anterior scalenes muscles; and strengthening of the shoulder external rotator muscles. Replacing screen time and other sedentary behaviors with physical activity (such as after school sports), as well as proper backpack use (using both straps, keeping the weight of the back higher on the back, and restricting the bag’s weight to less than 10-20% of the child’s bodyweight) are also strategies for avoiding poor posture.
If a teenager with neck pain and faulty posture presents for chiropractic care, treatment will include hands-on care in the office, which can include manual therapies and physiotherapy modalities. Between visits, the patient may be asked to perform exercises to restore muscle balance in the neck and upper torso to help correct their posture. Not only can this approach help relieve their neck pain, but it can also lower their risk for neck pain in the future!
Initial Provider Choice and Future Low Back Pain-Related Costs
Low back pain (LBP) is a global health problem that will affect most adults at least once in their lifetime. For many, LBP may become a chronic issue that can significantly affect their ability to work and carry out normal activities of daily living. While we often discuss how chiropractic care serves as an excellent front-line treatment for LBP, it’s seldom discussed how seeing a doctor of chiropractic first can save a patient and their insurer from future healthcare expenditures involving medications, advanced imaging, surgery, and adverse effects that can result from these services.
Advanced imaging such as MRI are often used to confirm a diagnosis, and in many cases, the findings can save lives. However, when it comes to low back pain, unnecessary imaging can lead to immediate costs and treatment that may not resolve the patient’s LBP and may place them at risk for harm. In 2018, researchers conducted a chart review of 313 patients referred for MRI and found that 130 imaging requests were unnecessary, which corresponded to a previous 2014 study that found 46.7% of MRI for LBP are inappropriate. A 2012 study that looked at data from the Washington State Worker’s Compensation system found that about 1 in 5 workers with LBP underwent an MRI within six weeks of their injury. Those who first went to a chiropractor were half as likely to be referred to MRI while those who first visited a surgeon were 78% more likely to receive advanced imaging.
While typically not advised in treatment guidelines, patients with chronic low back pain are often prescribed opioids. In a 2022 study that looked at long-term outcomes for Medicare beneficiaries with new-onset low back pain, researchers observed that those who visited a chiropractor first were 2.2 times less likely to be prescribed opioids within the following four years. Prolonged opioid use is associated with an elevated risk for misuse, as well as abuse of more serious and illicit drugs.
Treatment guidelines generally frown upon surgical intervention as a first step outside of emergency circumstances; however, a 2022 study found that 41.7% of patients who underwent back surgery in a sample of 2.5 million low back pain patients had minimal non-pharmaceutical, non-operative treatment in the six months before their operation. In fact, another study that used the Washington State Workers Compensation dataset found that low back pain patients were 29 times less likely to end up in the operating room if they first consult with a chiropractor. Not only is surgery costly and comes with a risk for complications and prolonged recovery, but in a July 2022 study, the authors noted that the failure rate of spinal surgeries may be as high as 40% with the majority of failures linked to misdiagnosis!
A June 2023 study that looked at data from a large insurer regarding more than 30,000 patients with new-onset LBP found that seeing a chiropractor first led to an immediate and long-term reduction in healthcare costs and the data “…provides a compelling case for the influence of the first provider on an acute episode of LBP.” Not only is chiropractic care a great conservative treatment option for individuals with low back pain but encouraging chiropractic as a first choice for care can not only provide immediate and long-term savings in healthcare expenditures, but it can also free up those resources for patients with healthcare conditions that may better benefit from their availability.
Manual Therapies for Most Carpal Tunnel Syndrome Patients?
Carpal tunnel syndrome (CTS) is a fairly common condition that occurs when the median nerve is compressed or its movement is restricted as it passes through the wrist. There can be many potential causes median nerve entrapment in the carpal tunnel from inflammation caused by overuse or chronic health conditions to mechanical injury. Treatment guidelines typically recommend the use of non-surgical therapies prior to surgical intervention, at least outside of emergency circumstances like a wrist fracture. But what non-surgical approaches offer the best chance for successful resolution?
A systematic review that included 461 published studies on the non-surgical management of CTS found that manual therapies offer the same long-term results as surgery with respect to reducing pain and improving function. Best of all, conservative approaches tend to carry fewer risks than surgery, and patients may experience significant improvement within weeks with nonsurgical care instead of months if they go under the knife. In the context of this review, non-surgical treatment options included mobilization techniques, massage therapy techniques, kinesiotaping, and yoga; however, among these options, which is the best bet for the CTS sufferer? In another systematic review with meta-analysis, researchers looked at 422 CTS cases and split them into two groups: those treated with manual therapies and those treated with other non-surgical options. In the context of symptom severity and functional capacity, manual therapies outperformed the other available treatments.
For patients whose CTS can be traced back to mechanical issues, it makes sense that manual therapies applied to the wrist can be a great choice. But what if a contributing or primary cause of the patient’s symptoms is due to systemic diseases like rheumatoid arthritis, hypothyroid, or diabetes mellitus? In a systematic review that included 29 randomized clinical trials that included data on whether or not the participants had a history of systemic diseases, the researchers found that manual therapies can benefit CTS patients with systemic diseases, even in patients with severe CTS symptoms, though more research needs to be done with this more challenging patient population.
Doctors of chiropractic offer an excellent treatment option for the CTS patient, often using a multimodal treatment approach that induces manual therapies, specific exercises, physiotherapy modalities, and nutrition recommendations with the aim of reducing inflammation to allow the median nerve to function properly and free of restriction. This includes checking the full course of the median nerve from the neck to the hand as compression in the neck, shoulder, elbow, or forearm is common in CTS patients and would need to be addressed to achieve a satisfactory result. If a patient has systemic health conditions, they may require co-management with the patient’s medical physician or a specialist.
The Multifactorial Problem of Frozen Shoulder
The condition that’s often referred to as frozen shoulder goes by many monikers: adhesive capsulitis, painful stiff shoulder, periarthritis, and idiopathic restriction of shoulder movement. Regardless of the name, frozen shoulder presents itself as a stiff, inflexible, and painful shoulder joint and it often arises in a mysterious way that’s sometimes difficult to trace. The etiology of frozen can be primary (typically, no known cause) or secondary to other conditions. Because of its often nebulous onset, there is great debate in the scientific literature regarding how to best manage the condition.
Frozen shoulder affects up to 5% of the world’s population, usually those between the ages of 40 and 60 years, and between 10% and 38% of those with diabetes or thyroid diseases. In addition to diabetes and thyroid diseases, other risk factors for frozen shoulder include Dupuytren’s syndrome, kidney stones, cancer, Parkinson’s disease, shoulder injury, smoking, post-stroke, heart and neck surgery, and chronic regional pain syndrome. Up to 85% of frozen shoulder patients have at least two risk factors for frozen shoulder, and nearly 40% have at least three!
Frozen shoulder is considered an inflammatory condition that causes fibrosis of the glenohumeral ball and socket joint capsule that leads to gradual progressive stiffness and significant loss of motion, especially external rotation. In its early stages, differentiating frozen shoulder from other shoulder pathologies can be quite challenging, but the process becomes much easier in its later stages. Erroneously, many healthcare professionals believe that frozen shoulder spontaneously resolves in most patients. Rather, the condition can persist for years and may never resolve if left untreated.
Generally, initial treatment for frozen shoulder is usually physical in nature including a mix of manual therapies, physical therapy, and patient-specific home exercises. Medical doctors may administer steroid injections or prescribe medications that can provide temporary relief, but since they have little impact on the accumulation of fibrotic collagenous scar tissue, the symptoms will likely return. If conservative options fail, surgical methods like open or arthroscopic capsular release and hydrodilation may be recommended to improve shoulder range of motion and alleviate pain, but these procedures may lead to complications.
As with many musculoskeletal conditions, frozen shoulder is easiest to manage in its earliest stages. Because of the nature of frozen shoulder, co-management to address comorbidities with the patient’s medical doctor may be necessary to achieve the best possible outcome in the shortest time.
Warning Signs for Chronic Whiplash
Whiplash injury can occur from any rapid acceleration/deceleration of the head and neck, and it can lead to a cluster of symptoms including neck pain, headache, dizziness/balance loss, fatigue, depression, irritability, mental fog, tinnitus, and more that is collected under the umbrella term whiplash associated disorders (WAD). The current data suggest that roughly half of WAD patients will experience chronic symptoms and 15% may report ongoing severe pain–related disability. Are there warning signs that manifest soon after injury that can help identify patients at risk for chronic and persistent WAD symptoms? Let’s find out…
In a November 2022 study, researchers looked at one year of data concerning 740 whiplash patients and found that those who experienced posttraumatic stress symptoms, sensory hypersensitivity, and neck pain-related disability early on were more likely to have chronic WAD at the close of the study. In a separate study, researchers observed that whiplash patients with higher pain intensity and sensory and motor dysfunction early on were more likely to have reduced work capacity a year later. The findings support the concept that WAD is a complex injury with several underlying mechanisms.
What can be done in the early phase of care to reduce the risk for chronicity, especially in WAD patients with one or more of the risk factors described above? First off, and most commonly associated with chiropractic care, is the adoption of a multimodal approach focused on relieving pain and improving function. This may include manual therapies (manipulation, mobilization, massage, or soft-tissue release techniques), physiotherapy modalities (electric stim, ultrasound, laser, or pulsed electromagnetic field), exercise training, dry needling, acupuncture, nutritional counseling, and more.
Another key component is patient education regarding maintaining as active a lifestyle as possible. That is, there’s a balance of activity modification to allow injured tissues the opportunity to heal and staying active to prevent the muscles in the neck and shoulders (especially the deep muscles that are used to stabilize the body and maintain good posture) from becoming deconditioned and atrophied. When these deep muscles weaken, the superficial muscles that are used for movement have to pick up the slack. Over time, the muscles can become overworked, increasing the risk for further injury. Psychosocial factors like depression and anxiety are often present in WAD patients, whether they manifest in response to injury or pre-existed it. If mood disorders or psychological factors may be inhibiting progress, the patient may be referred to a mental health professional to help co-manage their care.
Doctors of chiropractic have several tools at their disposal to help them monitor your pain intensity, disability, and activity tolerance while you’re under their care. This will not only help them document your recovery but also make changes to your treatment plan as needed.
Vitamin D and Healthy Aging
Vitamin D, also referred to as calciferol, is a fat-soluble vitamin that is present in a few foods, is added to others, can be taken as a dietary supplement, and is produced endogenously when ultraviolet rays from sunlight reach the skin and trigger vitamin D synthesis. While many people associate a lack of vitamin D with conditions like seasonal affective disorder or rickets, few know the benefits of vitamin D for healthy aging!
NEUROLOGICAL HEALTH: In one literature review, the authors reported vitamin D supplementation improved muscle strength and balance in older adults utilizing daily doses of 800 IU or more. Similarly, another group of authors performed a systematic review and meta-analysis and found vitamin D treatment effectively reduced the risk of falls in older adults with doses between 200-1000 IUs.
BONE HEALTH: Vitamin D promotes calcium absorption in the gut and maintains adequate blood levels of calcium and phosphate concentrations to enable normal bone mineralization, and it is needed for bone growth and remodeling. Without it, bones become thin, brittle, and/or misshapen. When taken together, calcium and vitamin D help prevent osteoporosis in older adults.
ANTI-INFLAMMATORY: Vitamin D reduces systemic inflammation, which may help prevent many diseases, including cardiovascular disease and some cancers.
EXERCISE: A systematic review that included ten studies concluded that vitamin D at a minimum dose of 2000 IU per day for more than seven days is an efficacious approach to attenuate muscle damage and inflammation after exercise.
BACK PAIN: One systematic review reported strong evidence on the causal relationship between lower vitamin D and increased low back pain incidence. They also observed that individuals with genetic predisposition for higher vitamin D serum levels were less likely to develop low back pain. The authors concluded that providers may consider recommending vitamin D for low back pain treatment and prevention reasons. Healthy vitamin D levels are also linked to a lower risk for muscle cramps and spasms.
Unfortunately, only about 15% of older adults in the United States have healthy vitamin D status and 42% have severely deficient vitamin D levels. In a 2023 study, researchers concluded that in order to attain optimal vitamin D levels through sun exposure alone, it’s recommended to spend at least five to ten minutes outdoors on most days during the summertime with at least 35% of the body exposed to the sun. However, during the winter when just 10% of the body may be exposed to the sun, an individual may need to spend up to 45 minutes outdoors during midday on a daily basis. Of note, those living in higher latitudes or with a darker complexion may require more time in the sun to create sufficient vitamin D. If consistently spending some time (or enough time) in the sun each day isn’t feasible, talk with your healthcare provider regarding recommendations on vitamin D supplementation and/or vitamin D-rich foods to add to your diet.
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.
