Monthly Pain Updates – January 2022
Low Back Pain
Chiropractic Care for the Post-Lumbar Fusion Patient
Between 1993 and 2013, the number of lumbar fusion surgeries for low back pain and related spinal conditions increased significantly from 61,000 per year to 450,000 per year! Unfortunately, up to 61% of patients who undergo back surgery will continue to experience chronic low back pain. Many of these patients will opt for non-surgical care to address their ongoing pain, which may lead them to consult with a doctor of chiropractic.
In fact, a survey of 62 chiropractors in the Veterans Administration healthcare system revealed that nearly 90% treated at least one post-fusion patient in the previous month and two-thirds treated between one to five such patients. Most often, these patients came from a referral from their medical physician, physical therapist, or orthopedic and neurological surgeon.
So, what can the post-fusion patient expect when he or she visits a chiropractor? In addition to taking a patient history and a physical examination, when the post-fusion patient presents for care, the chiropractor will often take x-rays, which may include weight-bearing (standing), neutral AP (front), and lateral (side) views, as well as x-rays taken in full flexion (forward bending) and extension (backward bending) positions. The importance of the x-ray assessment is to evaluate for fusion stability (i.e., fusion failure) and to look for broken screws and other hardware malfunction that may require a referral back to their surgeon. Additionally, the x-rays will allow the doctor of chiropractic to assess the levels above and below the fused segments because it’s common for these joints to become hypermobile, which can lead to injury and pain. Depending on the individual case, a CT and/or MRI may be appropriate as these can offer further diagnostic information such as the presence of spondyloarthopathies, a tumor, infection, intervertebral disk herniation, postoperative scar or fibrosis formation, and more.
Though large-scale, randomized controlled trials to assess the efficacy and safety of chiropractic care for the post-fusion patient have not been completed, there are several case reports and series that have shown that the techniques often used for the general low back pain population are similarly as effective. These include high-velocity, low amplitude manipulation, mobilization, and soft tissue techniques, as well as specific exercises targeted to the core muscle groups and even nutrition instruction. Perhaps most important, in all the papers published to date regarding chiropractic treatment of the post-fusion low back pain patient population, no serious adverse effects have been reported and no patients have required surgical intervention following chiropractic care.
Neck Pain / Headaches
Chiropractic Treatment for Forward Head Posture
Forward head posture is a common postural fault in which the head’s center of gravity rests forward of the sagittal plane, and it’s typically associated with frequent electronic device and screen use. The further the head sits in front of the shoulders, the harder the muscles in the back of the neck, shoulders, and upper back must work to keep the head upright. In addition to pain in the neck, upper back, and shoulders, forward head posture has been linked to headaches, respiratory impairments, and reduced nerve conduction in the cervical spine. Aside from general advice to limit screen time and sit up straight, what treatment options might benefit the patient with forward head posture?
A 2021 randomized trial compared scapular stabilization exercises (SSE) to no exercise in 39 young women with forward head posture. The exercise group performed SSEs using elastic bands at ten reps a set, three sets a day, and three days a week for four weeks. The control group did not perform any exercises. Results showed improvement in forward head posture in only the exercise group.
Another study compared SSE with abdominal control feedback (ACF) in 135 women with forward head posture who were separated into three groups: SSE and ACF; SSE only; and general exercise. The results showed that the individuals in the SSE and ACF group had the best outcomes with respect to posture, pain, balance, and strength.
In 2019, a study compared mobilization therapy of the neck and upper back with deep neck flexor exercises in a group of 31 patients with forward head posture. The results showed the patients in the mobilization group were more than twice as likely (60% vs 25%) to report significant improvements in cervical posture, pain, and respiratory function.
Two years previous, the same research team compared upper thoracic (UT) mobilization with mobility exercises verses upper cervical (UC) spine mobilization with stabilization exercises in 32 participants with forward head posture for four weeks. Outcome assessments showed that 11 of 15 patients in the UT group experienced significant overall improvement compared to 8 of 16 patients in the UC group. Additionally, members of the UT group exhibited greater improvement with respect to cervical posture.
The results from these studies suggest that specific exercises and manual therapies are effective for managing the patients with forward head posture, especially when used together. Doctors of chiropractic frequently use a multimodal approach when managing patients with musculoskeletal disorders in order to achieve the best outcome for the patient.
Joint Pain
Why Women May Be More at Risk for Knee Pain
The anatomical and physiological differences between men and women are obvious in many ways. But one way that’s often overlooked is how these differences relate to kne-related injuries, of which women may be between two-to-eight times more at risk for than men.
When it comes to the lower extremities, an issue in the foot, ankle, knee, hip, or low back can cause one to move differently, which can cause biomechanical changes elsewhere along the kinetic chain. These alterations can place additional stress on the joints, which can lead to an elevated risk for injury. As such, a problem in the feet or in the hips can affect the knees.
Researchers have observed that differences in the anatomy of the feet of men and women can lead to variations in how loads are distributed in the foot, and these differences become more apparent at the onset of puberty. For example, female feet and ankles have greater joint mobility and ligament flexibility, which can increase the risk for ankle sprains. A woman’s arch will also flatten (pronate) more while walking, which can increase the risk for heel pain, tendonitis, bunions, calluses, and more. Additionally, footwear choices, such as high heels, can also alter the biomechanics of the foot, which can change normal joint motion elsewhere along the kinetic chain.
In addition to differences in the feet, the anatomy of the hip can differ between men and women. Generally, females have wider hips. This means the angle the femur makes from the hip to the knee is greater, which can place more stress on the knee. This can potentially elevate the risk for “genu valgus” (knocked-knee), which can give rise to ACL tears and patellofemoral (knee-cap) pain syndrome—both of which are more common in women than men.
While it’s not currently possible to easily alter one’s anatomy in the foot, hips, pelvis, or knees, it is possible to address musculoskeletal disorders in these various areas before they can lead to secondary injury elsewhere, which can include the knees. For example, some problems in the foot can be addressed with orthotics. Your doctor of chiropractic can also apply manual therapies and provide instruction on stretches to restore normal motion to the affected joints so abnormal pressure is not applied to the knees.
Carpal Tunnel Syndrome
Conditions That Can Be Mistaken for Carpal Tunnel Syndrome
Carpal tunnel syndrome (CTS) is a potentially painful and disabling condition in which the mobility or function of the median nerve is restricted as it passes through the wrist. But the median nerve is not the only nerve that extends into the hand and entrapment of these other nerves can produce symptoms that may be mistaken for CTS.
ULNAR NERVE ENTRAPMENT: The ulnar nerve originates in the neck from the C8 and T1 nerve roots. Its most common entrapment site is the inner elbow (cubital tunnel syndrome) followed by the wrist (Guyon tunnel syndrome). Because the ulnar nerve innervates the pinky and outer half of the ring finger, that’s where numbness and tingling are felt. Less commonly, weakness of the grip, particularly the ring and pinky fingers can’t pinch a piece of paper (called positive Froment’s sign).
RADIAL NERVE ENTRAPMENT: The radial nerve arises from the C5-T1 nerve roots in the neck and innervates most of the back of the forearm and outer hand, and that is where numbness is felt. It also innervates the muscles involved in elbow and wrist extension, so if weakness is observed in these muscles, then it may suggest radial nerve entrapment. The radial nerve can be pinched in the axilla (arm pit) from a crutch that is used too long or improperly. Shoulder dislocations and fractures of the upper arm bone (the humerus) can also lead to radial nerve entrapment.
BRACHIAL PLEXUS INJURY: The brachial plexus is made up of a network of nerve fibers from C5-T1 nerve roots and ultimately give rise to ALL of the nerves that innervate the upper extremity. Although far less common, injuries here can affect any part of the arm. One such injury can occur due to a difficult vaginal birth, which over-stretches the neck and shoulder/arm and is called Erb’s Palsy. This results in an injury to the C5-6 roots causing the arm to hang limply and rotate inward with the wrist flexed. This position is known as the “waiter’s tip”. Although less common, difficult births can also injure the lower brachial plexus (C8-T1), which is called “Klumpke’s Palsy”, which caused the hand to take a fixed claw-like position.
As you may have observed, these various nerves each innervate different parts of the hand and fingers, which helps your doctor of chiropractic identify which nerve may be entrapped. Once this is established, they can administer tests along the course of the nerve to identify areas where nerve mobility or function may be restricted so they can formulate a treatment plan. To complicate matters, nerve entrapment can occur in multiple areas. Likewise, a patient can have entrapment neuropathies in two nerves simultaneously, which may require a more comprehensive approach to resolve the patient’s symptoms.
Doctors of chiropractic have extensive training in anatomy, physiology, and pathology and are clinically trained to differentiate, identify, and treat these various conditions. There are many non-surgical treatment options offered by your chiropractor to help you through the healing process.
Whiplash
Factors Linked to Chronic Whiplash Associated Disorders
Whiplash associated disorders (WAD) is a term that describes the cluster of symptoms that can arise from an injury caused by the sudden acceleration and deceleration of the head and neck, most often seen in a motor vehicle collision. Whiplash injuries are classified in four levels: WAD I (no/minimal complaints/injury); WAD II (soft-tissue injury—muscle/tendon and/or ligament injury); WAD III (nerve injury); WAD IV (fracture). The current research suggests that between 20-50% of WAD patients will continue to experience some degree of life-interfering pain and disability a year following their initial injury. Several studies have sought to uncover why some patients develop chronic WAD (or cWAD) while others have a full recovery.
Among the risk factors associated with cWAD, a higher initial pain intensity and higher initial disability scores—which are indicative of more severe injury—are two of the most important. Thus, a patient with WAD II is at greater risk for chronic symptoms than the WAD I patient. Likewise, patients with WAD III have a higher risk for chronic pain and disability than those with WAD II. With respect to physical characteristics, individuals with a more slender and less muscular neck have an elevated risk for more serious injury, as do those with weaker neck muscles, arthritis in the cervical spine, and a history of neck pain.
Additionally, there are two more prominent risk factors for cWAD, but they are related to the response to injury. These factors are pain catastrophizing (describing pain in more negative and exaggerated terms) and poor expectation of recovery. These can be attributed to the patient having a poor understanding of their condition. When this occurs, the patient is more likely to let their pain get the best of them and restrict their activities. This can lead to deconditioning of the neck muscles (or the body in general), which can slow the recovery process.
For the best chance of a full recovery, doctors of chiropractic provide manual therapies like spinal and extremity joint manipulation (high-velocity thrust), mobilization (low-velocity non-thrust), manual traction, massage, assisted-stretch, neuro-motor retraining manual methods, and a host of soft-tissue therapies. The chiropractor may also employ modalities like electric stim, ultrasound, pulsed electro-magnetic field, class IIIb or IV laser, and more. Patients are also encouraged to remain active to help them feel more in control of their recovery and can keep the muscles in the neck from becoming deconditioned.
While the multimodal approach utilized by doctors of chiropractic is recommended by treatment guidelines as preferred front-line treatment, the chiropractor may co-manage the patient with allied healthcare providers such as a medical physician, physical therapist, acupuncturist, or psychologist to address aspects that fall outside their traditional scope of care.
Whole Body Health
Low-Fat Diet, Yay or Nay?
For decades, the public has been told to avoid whole milk and other foods containing full-fat dairy products because such fare will clog arteries and promote cardiovascular disease. A trip around the grocery store will show many food products labeled as low-fat or fat-free. Even today, the American Heart Association warns us about this on their website and recommends that we substitute fat-free (skim or “light”) milk and low-fat yogurt or cheese in place of full-fat equivalents. Despite the embrace of low-fat dietary practices, obesity has become an epidemic. In fact, the obesity rate among children has doubled in the last two decades alone, which brings about an increased risk for poor health in adulthood. So is a low-fat diet still a solid recommendation?
A July 2021 randomized controlled trial published in The American Journal of Clinical Nutrition compared the impact of low-fat vs. full-fat dairy foods on fasting lipid blood levels and blood pressure in 72 men and women with metabolic syndrome—a cluster of conditions (high blood pressure, abnormal blood lipid levels, high fasting blood sugar, and excessive waist circumference) that occur together and increase the risk of heart disease, stroke, and type 2 diabetes. Study participants began by limiting their dairy intake to less than three servings a week of non-fat milk for four weeks. Then, they were assigned to one of three diets: no-change, continue to limit dairy to less than three servings of non-fat milk a week; switching to 3.3 servings of low-fat milk, cheese, or yogurt a week; or switching to 3.3 servings of full-fat milk, cheese, or yogurt a week. After twelve weeks, the researchers did not observe a difference in blood lipid readings or blood pressure levels between the three groups.
On the other hand, a meta review of previous studies did find that restricting carbs can improve blood pressure and blood lipid levels. However, this does not mean one should consume as much fat as possible in their diet. Not all fats are the same, and studies have shown that increased consumption of saturated fats and trans fats can be detrimental to one’s health. Trans fats are used to prolong shelf life in highly processed foods and should be avoided. Saturated fats are found in dark poultry meat; fatty cuts of beef, pork, and lamb; high-fat dairy products; lard; and tropical oils (coconut and palm, for example). Health experts recommend limiting saturated fat consumption to less than 5-6% of total calories per day, which may explain why the full-fat dairy group did not experience any increase in blood lipid or blood pressure compared with the low-fat dairy group in the study noted above.
If one desires a diet featuring healthy fats, low-carbs, and fewer unhealthy fats, a good option to consider is the Mediterranean diet. This eating pattern focuses on eating fruits, vegetables, nuts, fish, olive oil, and whole grains while avoiding red and processed meats, dairy, saturated fats, and refined sugars. Not only has the Mediterranean diet been observed to lower the risk for heart disease but it also helps to reduce inflammation in the body, which has been associated with an increased risk for chronic musculoskeletal pain. That’s why doctors of chiropractic may encourage patients to engage in healthier dietary practices in order to aid in the healing process and to reduce the risk for recurrence.
