MONTHLY HEALTH UPDATE
How Does Chiropractic Stack Up for Low Back Pain?
Chad Abramson, D.C.
Whole Body Health
Can Chiropractic Help GERD?
There is a plethora of research supporting the benefits of chiropractic care for many
musculoskeletal (MSK) complaints including low back pain, neck pain, headaches, and
more. However, less research is available for non-MSK complaints like gastroesophageal
reflux disease, or GERD. So, what can chiropractic offer patients with GERD, and why is
Normally, when we chew and swallow food, it passes through the lower esophageal sphincter (LES), a ring of muscle that opens to let food pass into the stomach and then closes to prevent food and acids from flowing back into the esophagus. If the LES is weak or relaxes inappropriately, individuals can experience the symptoms associated with GERD, including an acidic taste in the mouth, chest pain, choking, difficulty or inability to swallow, nausea, and/or burning sensation in the stomach and/or chest. More than 60 million Americans experience GERD at least once a month with 15 million adults suffering daily from the condition. The persistence of GERD can damage the esophagus, which can lead to inflammation and a breakdown in the lining leading to erosions, ulcerations, fibrotic scarring, and though rare, it can lead to cancer of the esophagus.
Common causes of GERD include (not all-inclusive): hiatal hernia, in which the stomach slides or rolls up above the opening in the diaphragm allowing acids that normally stay in the stomach to flow easily into the esophagus; excess weight from obesity or pregnancy, which can apply pressure against the stomach promoting acid reflux into the esophagus; a diet rich in fatty and/or spicy foods, chocolate, peppermint, coffee, or alcohol; eating late at night; poor posture (slumped); smoking; certain medications; and stress.
In a 2016 study, 22 middle-aged adults with a history of GERD (mean 20.4 months) received between three and sixteen treatments consisting of thoracic spinal manipulation, diaphragm mobilization, traction of the cardia, and posture correction—all of which can be provided in a chiropractic setting. All but two patients reported significant improvements that persisted up to three months following the conclusion of care.
In addition to the manual therapies listed above, your doctor of chiropractic can teach you exercises and offer nutritional advice to help manage GERD without the use of medications.
Is There a Difference Between Whiplash and Non-Whiplash Neck Pain?
When we hear the term “whiplash injury,” we likely think of car crashes, though
whiplash can result from other causes, like a fall or sports collision. Though whiplash is
associated with a variety of symptoms, neck pain with lower pain thresholds (called central
sensitization) is one of the most common. Neck pain can also occur in the absence of trauma
or a known pathology. This is called mechanical neck pain (MNP).
Past research has shown that the combination of manual therapies (including
mobilization and manipulation) and neck-specific exercises can benefit patients with neck
pain, but is there a different treatment response between whiplash patients and MNP
A 2017 study evaluated this very question. The authors recruited 28 patients with either grade I or II whiplash (pain with or without exam findings but no neurological losses) and 22 MNP patients. The patients in the MNP group were only included if their symptoms could be provoked by changes in cervical posture, neck movement, and palpation of certain neck muscles. The research team measured neck pain intensity, neck-related disability, pain area, cervical range of motion, and pressure pain thresholds (the amount of pressure measured to induce pain using a spring-loaded pressure gauge) both initially at baseline and again after six treatment sessions.
The results showed that whiplash sufferers initially had significantly higher painrelated disability, larger pain area, and central sensitization. In spite of this, the investigators observed that after six treatments, the patients in both groups achieved similar improvements with respect to cervical range of motion (flexion/extension, left/right side bending, and rotation), neck pain intensity, neck pain-related disability, pain area, and pressure point thresholds. However, the whiplash patients continued to experience a lower pain threshold than participants in the MNP group. The good news for whiplash patients is that another 2017 study demonstrated that treating painful myofascial trigger points can help restore pain thresholds.
Doctors of chiropractic frequently utilize the two treatment approaches from this study—manual therapy and specific neck exercises—in addition to other management approaches to achieve successful outcomes for patients with neck pain, either whiplash or MNP.
Neck Pain / Headaches
Let’s Have Some “Pillow Talk!”
Individuals with neck pain may find it difficult for get a night of restful, restorative sleep
due to pain keeping them awake or interrupting their slumber. Not only can a restless night make
it more difficult to complete tasks related to everyday living or make neck pain worse, but poor
sleep habits over time can raise one’s risk for chronic disease and even early death—perhaps as
much as physical inactivity or a bad diet. When treating a patient with neck pain, doctors of
chiropractic often inquire about the patient’s sleeping position and pillow, as addressing these
factors may be important for getting a good night’s rest.
When it comes to a “good” position for the head while sleeping, most experts would recommend assuming a position that most closely mimics a good upright posture. If lying on the back, the head should not be forced toward the chest (hyper-flexed) or dropped too far backward into hyper-extension. When lying on the side, the head should not be forced upward or downward, away from the neutral position. If you habitually sleep on your stomach—which is generally NOT a good position for the neck due to the prolonged static rotation—you may want to consider a very thin pillow (or not using a pillow) to not force the neck too far up or down when rotated. Placing a body-pillow between the knees that extends up in front of the pelvis and chest can function as a “kick-stand” to keep you from rolling onto your stomach during the night.
What about pillow materials? There are many to choose from, such as feathers, foam (memory and others), water, buckwheat, and/or combinations of these. While there is probably not a “best” choice, there are characteristic differences that are worth discussing. For example, memory foam molds nicely to the contours of the head and neck but can be hot and may have an unpleasant odor. Latex foam has the advantage of molding well to contours without becoming hot and comes in various densities to suit preferences, which can be quite helpful for those with neck pain and headaches. Generally, higher density foam offers less breakdown and more support. Latex is also resistant to mold and dust mites, another distinct advantage. Feathers and down pillows can mold to fit the body contours nicely but have a tendency to lose that initial position as the feathers often spread out while sleeping. Some people are also bothered by allergies or skin sensitivities making feather pillows and certain types of foam undesirable. Buckwheat hulls tend to mold well and be cool but then can be noisy when moving. Mattress firmness should also be taken into consideration, as the amount of “sinking in” will affect the pillow thickness decision.
If musculoskeletal pain is interfering with your sleep, consult with your doctor of chiropractic to help determine the best position and pillow for your individual case. Your chiropractor may also offer nutritional recommendations with the aim of improving sleep quality.
What Is Patellofemoral Pain?
While chiropractic care commonly focuses on improving function in the spine to reduce neck
pain and back pain, in many cases achieving a successful outcome is only possible when treatment
addresses conditions elsewhere in the body. For example, ANY painful condition of the knee can
alter one’s gait pattern, which can result in abnormal movement in the ankle, pelvis, and lower back,
potentially leading to musculoskeletal pain in those areas as well. In this article, we’ll focus on
patellofemoral (PF) pain, or pain that arises in the region of the knee cap, as it’s one of the more
common knee conditions.
The anatomy in and around the patella is unique in several ways. First, the patella is the largest “sesamoid” (free-floating) bone of the body. The role of all sesamoid bones is to improve the function of the muscle/tendon connecting to the sesamoid bone by optimizing the angle of action. In effect, it acts like a pulley, which significantly improves the strength and force of the muscle. The quadriceps muscles attach above at the pelvis and below at the upper pole of the patella. The patella then glides in a grove, or track, located in the distal femur (thigh bone) and a tendon then attaches the lower pole of the patella to a bony prominence located just below the knee on the proximal tibia, or upper “shin bone.”
When we flex and extend our knee, the patella slides up and down in the track as the quadriceps contract and relax. This occurs automatically when walking, running, climbing, etc. Of the four muscles that make up the quadriceps, three (rectus femoris, vastus lateralis, and vastus intermedius) pull the patella up and out when we extend or straighten the knee and only one (vastus medialis) pulls the kneecap up and inward. To compensate for this disadvantage, the vastus medialis normally fires first during knee extension, which allows for proper patellar tracking and normal function.
A 2018 study published in the Archives of Medicine and Rehabilitation looked at the “neural drive” of the four quadriceps muscles in 56 women with or without PF pain. Subjects were asked to sustain an isometric, or static knee, extension contraction at 10% of their maximum effort for 70 seconds. Specialized nerve testing tools measured the average firing rates at various time points during muscle contraction. In the non-PF pain subjects, the vastus medialis fired at higher rates vs. the largest muscle (the vastus lateralis) that pulls the patella up and out. This was the opposite case in the women with PF pain, which investigators suspect may cause and/or perpetuate PF pain.
This finding has led to the recommendation of isolating the vastus medialis with a specific strengthening exercise. This is accomplished by emphasizing the last ten degrees of full knee extension by completely locking or straightening out the knee in extension followed by only a slight bend. This is repeated 10-20 times with or without weight, depending on the degree of injury, pain, and muscle weakness. Your doctor of chiropractic can help train you in performing this exercise properly, as well as offer other highly effective exercises and treatments for knee pain.
Carpal Tunnel Syndrome
How Does Wrist Position Affect the Carpal Tunnel?
Carpal tunnel syndrome (CTS) is the most common “peripheral neuropathy” (pinched nerves in the arms or legs) and is known to be caused by prolonged repetitive, forceful griprelated tasks involving the hands. The condition occurs when pressure is placed on the median nerve as it passes through the carpal tunnel, either from inflammation, mechanical injury, or both. The position of the wrist and hand are very important, as the pressure inside a healthy wrist “normally” doubles when we bend the wrist/hand. However, when CTS is present, the pressure doesn’t double at the extreme end-ranges of motion. Rather, when inflammation is present, pressure can increase up to six times at the end-ranges of motion! This can be highly problematic at night because we don’t have much control over how we position our wrist. Not only can increased pressure on the median nerve cause you to wake up but it can set the stage for worsening symptoms in both the short and long term. This is why doctors often advise CTS patients to wear a night splint and to avoid prolonged awkward wrist positions during the day when working. In a 2014 study involving 31 healthy college students, researchers used ultrasonography to measure median nerve deformation as participants bent their wrists and performed finger movement-intensive movements. Investigators observed that the median nerve flattened out with as little as 30º of wrist extension and became swollen after students performed rapid mobile-phone keying for five minutes with a corresponding increase in the cross-sectional area of the carpal tunnel. In a follow-up experiment, the research team found that the motion involved with clicking a mouse repeatedly had an even greater effect on the median nerve. The authors concluded that the increased use of electronic devices, especially in non-neutral wrist positions, increases the risk of CTS. A literature review performed in the same year came to a similar conclusion: prolonged exposure to non-neutral wrist postures increased CTS risk by at least twofold. In order to reduce pressure on the median nerve, doctors of chiropractic often use a combination of wrist splinting, patient education (including tool/workstation modifications), nutritional recommendations, and manual therapies. In many cases, this can lead to a successful outcome without the need for more invasive treatments. However, when necessary, your chiropractor can refer you to the appropriate provider and/or co-manage the condition with them.
Low Back Pain
Can Exercise Prevent Low Back Pain?
While it’s not possible to totally prevent low back pain (LBP), individuals who regularly exercise
appear to have a reduced risk for LBP. Additionally, fit adults who develop back pain may experience it
less often, at a reduced intensity, and for a shorter duration than those who lead a more sedentary lifestyle.
Which type of exercise is the best? A general rule is to keep trying different activities, starting
with those MOST appealing to you. After all, you should enjoy exercise, so start with your favorites:
walking (one of the best), walk/run combinations, running/jogging, bicycling, swimming/water aerobics,
yoga, Pilates, core strengthening, balance exercises, tennis, basketball, golfing, etc.
Specific exercises for the low back can be individualized by determining your "position preference", or the position that feels best to your low back. For example, bend forward as if to touch your toes. How does that feel? Do you feel a good stretch or pain? Does it shoot pain down your leg? If it feels good, then that might be your preferred position and the one to emphasize with exercise. Examples of exercises that fit this scenario include (but are not limited to): posterior pelvic tilts (flatten your low back by rocking your pelvis forward); single and double knee to chest; and bending forward from a chair (as if to touch the floor).
If bending backward feels good (better than flexion and especially if the presence of leg pain lessens or disappears), then “extension-biased” exercises fit that scenario. Examples include standing back extensions (place your hands behind the low back and bend backward); prone "press-ups" (lift the chest off the floor while keeping the pelvis down); and laying back-first over a Bosu- or Gym-ball. Pelvic dysfunction and core weakness can also increase the risk for LBP. Try these exercises: abdominal crunches (bend one knee, place your hands behind your low back, and raise the breast bone toward the ceiling only a few inches and hold); front and side planks (start from the knees if necessary); supine bridges (supine, knees bent, lift the buttocks off the floor); “bird-dog” (kneel on all fours and raise the opposite leg and arm, keep good form, and alternate); and the “dead-bug” (on your back, bend the hips and knees at 90 degrees with your arms reaching toward the ceiling; slowly lower your right arm and left leg and return them to their starting position; repeat with the other arm/leg).
When lifting, bend the knees and hips but NOT your low back; keep weights close to you and lift with your legs. Don’t attempt lifts that you know are too heavy.
If you have a history of low back pain, research shows that receiving maintenance chiropractic care can help reduce the number of days in which low back pain may hinder your activities.
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This information should not be substituted for medical or chiropractic advice. Any and all health care concerns, decisions, and actions must be done through the advice and counsel of a health care professional who is familiar with your updated medical history.