MONTHLY HEALTH UPDATE
Can the Outcome of Back Pain Be Predicted?
Chad Abramson, D.C.
Low Back Pain
Chiropractic Care During Pregnancy for Back and Pelvic Pain
Low back pain (LBP) and posterior pelvic pain (PPP) are very common
complaints during pregnancy. In fact, current estimates show that two-thirds of
expectant mothers will experience back pain during pregnancy and one in five will
report pelvic pain. These afflictions can have a significant impact on a woman’s
quality of life and her ability to carry out everyday tasks. So, where does chiropractic
care fit into this picture?
While some pain conditions associated with pregnancy may be related to changes in certain hormones, there is evidence that the growing fetus shifts the center of gravity forward in a woman’s body. This shift can greatly affect the biomechanics of the body and place added strain on the lumbar and sacroiliac joints, giving rise to pain in those areas.
A landmark 2014 study looked at the effect of chiropractic treatment on 115 pregnant women with LBP/PPP. In a nutshell, 52% improved with respect to pain and disability after just one week of care, 70% after one month, 85% after three months, and 90% after six months.
Interestingly, the patients who had LBP/PPP prior to pregnancy tended to have higher pain scores at the conclusion of the study than those without a previous history of LBP/PPP. This finding supports the theory that women who have a history of LBP prior to pregnancy are particularly good candidates for chiropractic care early in their pregnancy. Also, due to a common link between persistent LBP after pregnancy and pre-pregnancy LBP, chiropractic care post-partum may be equally important. This study included many chiropractors in various locations, and treatment was not standardized to any one specific method or technique. That being said, high- velocity, low-amplitude spinal manipulative therapy was the most common approach utilized and is the “standard of care” utilized by most chiropractors around the world. As further research is conducted, it seems clear that the use of SMT during pregnancy will become “the norm”.
Neck Pain / Headaches
Neck-Specific Exercise for Headaches & Neck Pain
As screens (televisions, computers, and smartphones/tablets) become an
increasingly important part of daily life, many people gradually take on a more
slumped posture, which can place added strain on the neck and shoulders, raising the
risk for neck pain and headaches. Luckily, it’s possible to improve forward head
posture, rounded shoulder posture, and scapular instability with neck-specific
exercises and chiropractic care.
In a 2018 study, patients with forward head posture performed either scapular stabilization or neck stabilization exercises for 30 minutes three times a week for four weeks. Participants in both groups experienced improvements related to their craniocervical angle and muscle activity around the upper back and neck, with greater results reported by the scapular stabilization group.
Several studies have shown similar results for improving forward head posture using both scapular and neck stabilization exercises. In another study, high schoolers with forward head posture performed scapular and neck stabilization exercises and exhibited good posture up to four months later.
A 2019 study looked at the effect of a six-week intervention featuring manual therapy and/or stabilizing exercises on 60 women with neck pain and forward head posture. Participants in both the manual therapy/stabilization exercise-combo group and the stabilization exercises-only group reported better outcomes with respect to head posture, pain reduction, and improved function, but the results were best in the combined treatment group. The authors concluded that manual therapy adds a meaningful role to a structured exercise program that addresses scapular and neck instability and forward head and rounded shoulder posture.
Doctors of chiropractic often incorporate exercise training in their treatment recommendations, especially when postural issues may contribute to the patient’s symptoms, like neck pain and headaches.
Dynamic Stretching for Hip Pain
As we grow older, stretching becomes a more important part of our routine, especially
when hip pain is present. Whether you are about to engage in a sport, a job, weight lifting, or
errands, it’s best to prepare your muscles for activity. With that said, stretching can be broken
down into two main types: static (or passive) and dynamic (or active) stretching.
The available research notes that static stretching (stretching while holding one position, like reaching for your toes) has recovery benefits and is most effective at the end of a workout/competition. However, it can reduce performance when done beforehand, as it relaxes muscles, reduces blood flow and muscle strength, and decreases central nervous system (CNS) activity.
Active warm-ups or dynamic stretching have the opposite effect—they boost blood flow and activate the CNS, which enhances strength, power, and range of motion (ROM) resulting in BOTH immediate and long-term benefits. A 2014 systematic review of 31 studies reported that dynamic stretching that included sprints and plyometrics (movements against resistance) enhanced power and strength performance when compared to static stretching—which did not reduce strength. In a 2010 systematic review of 32 studies investigating active warm-up before engaging in a sport, researchers found that an active warm-up improved performance by 79% across all criteria investigated.
But what about the hip? A 2019 study compared static stretching vs. dynamic stretching of the hip joint with no-load (DSNL), with a light-load (DSLL, 0.25kg), and with a heavy-load (DSHL, 0.5kg) in an elderly population (63.2 ± 7.13 years). Participants stood sideways behind a chair (for balance), and swung one leg, as able. Researchers measured hip flexion and extension range of motion before the test, immediately after, and 60 minutes later. Compared to static stretches, all three types of dynamic stretches improved hip ROM more effectively at all time points, with DSNL being the most effective.
Here are a few hip-specific dynamic stretch options: 1) Standing Hip Circle: Stand on one leg, raise the opposite knee to 90o (thigh parallel to the floor); move the knee outward (open your hip), and make wide circles for 30 seconds/side or to fatigue (start gradually). 2) Lunge: Step forward with the right foot, lower the back knee toward the floor (as able); pause and repeat on the other leg. 3) Half Squat: From standing, slowly bend the knees until the thighs are parallel to the ground while bracing the core and maintaining a neutral low back curve.
Carpal Tunnel Syndrome
Factors That Can Hinder Carpal Tunnel Syndrome Recovery
As with most musculoskeletal conditions, treatment guidelines for carpal tunnel
syndrome (CTS) recommend non-surgical or conservative management initially, with
surgery only in emergency situations or after non-surgical options are exhausted. So, is
there a way to know who will respond best to non-surgical approaches?
To answer this, researchers conducted a two-stage study that included an initial
evaluation followed by non-surgical treatment and a re-evaluation one year after non-
surgical treatment concluded. The primary goal of the study was to assess factors
contributing to the long-term effects of non-surgical treatment of CTS and to identify
failure risk factors.
The study involved 49 subjects diagnosed with CTS, of which an occupational cause was identified in 37 (76%). Because some patients had CTS in both hands (bilateral CTS), a total of 78 hands/wrists were included in the study. Treatment included a total of ten sessions of whirlpool massage to the wrist and hand, ultrasound, and median nerve glide exercises performed at home. The subjects were divided into three age groups: 50, 51-59, ≥60 years old.
While most patients experienced significant improvement in both stages of the study, some did not. Patients with more severe cases, as evidenced by poor results on a nerve conduction velocity (NCV) test, were less likely to respond to care, which underscores the importance of seeking care for CTS as soon as symptoms develop. Furthermore, participants who continued to overuse their hands at work or who did not modify their work procedures or workstation to reduce the forces applied on the hands and wrist were less likely to report significant improvements at the one-year point. Interestingly, age was not found to be a significant risk factor, which is surprising, as past studies have reported that being age over 50 is a risk factor.
Not only are doctors of chiropractic trained in the same non-surgical treatment methods used in this study, but they can combine such approaches with nutritional counseling (to reduce inflammation) and manual therapies to improve function in the wrist and other sites along the course of the median nerve to achieve the best possible results for their patients.
Multi-Modal Care for Whiplash Patients
The term whiplash associated disorders (WAD) describes a constellation of symptoms
that includes (partial list) pain, stiffness/limited motion, dizziness, headache, depression/anxiety,
and brain-fog. The condition is associated with accelerations/deceleration events like car
accidents, sports collisions, or slip and falls. Such injuries are classified into four categories:
WAD I (no/minimal complaints/injury), WAD II (soft-tissue injury – muscle/tendon and/or ligament injury), WAD III (nerve injury), WAD IV (fracture). More than 85% of those involved in a motor vehicle collision (MVC) experience neck pain, with 29-40% recovering within a little more than three months and about 23% still not having recovered after one year. A 2016 systematic review generated treatment guidelines for patients with WAD and/or neck associated disorders (NAD) in the context of both a recent injury and for cases in which pain has persisted for longer than three months. Importantly, these guidelines were formed with input from several types of healthcare providers, including doctors of chiropractic, medical doctors, and physical therapists.
For recent-onset neck pain (0-3 months), the authors recommend multimodal care (multiple types); manipulation or mobilization; range-of-motion home exercise or multimodal manual therapy (for grades I-II NAD); adding supervised graded strengthening exercise (grade III NAD); and multimodal care (grade III WAD).
For persistent neck pain (more than 3 months), the review recommends multimodal care or stress self-management; manipulation with soft tissue therapy; high-dose massage; supervised group exercise; supervised yoga; supervised strengthening exercises or home exercises (grades I-II NAD); multimodal care or practitioner's advice (grades I-III NAD); and supervised exercise with advice or advice alone (grades I-II WAD). For patients with persistent neck and shoulder pain, evidence supports mixed supervised and unsupervised high-intensity strength training or advice alone (grades I-III NAD). The term, “multi-modal care” is defined as a grouping of manipulation, mobilization, and soft tissue techniques (myofascial release, contract-hold, trigger point therapy, muscle energy, and more). Multi-modal care may also incorporate the use of hot or cold packs, assisted stretching, advice to stay active or modify activity, and neck/shoulder exercise training. Doctors of chiropractic often take a multi-modal approach when treating patients with musculoskeletal pain, including those with whiplash associated disorders.
Whole Body Health
The 25-Second Balance Challenge
Since falls are a major cause of serious injury, especially for older adults, here’s a
simple way to objectively measure and improve your sense of balance...
First, stand in a place where you can catch yourself from falling (like behind a chair
or in a corner). Place your feet side by side for ten seconds. Then, place the heel of one foot
next to your big toe for ten seconds. Finally, rest the forefoot fully in front of the other (like
standing on a tight rope) and wait ten seconds. If this process presents no issues, you can
Stand on one foot/leg for up to 30 seconds with your eyes open. Next, switch legs and
repeat the process. Switch back to the first leg, get your balance, and start a 25 second timer.
Close your eyes and see if you can maintain your balance for the full 25 seconds. If you must open your eyes and put your foot down, keep track of your time and try the exercise up to three times in a row to see if you can improve. Repeat this on the opposite leg. The 25-second “cut-off” for “eyes closed” is published as the “norm” for those up to 59 years old. If you are 60-69 years old, the norm drops to ten seconds and if you are 70-79, the norm is only four seconds! This means we NORMALLY lose our sense of balance with age, but that doesn’t mean you should accept it, as retraining your balance system is feasible with the proper exercises.
First, practice the test described above, as it is also a great exercise for improving balance. Other balance challenges can include the use of a balance or rocker board, walking like you’re on a tight rope, walking backward, hopping in place, and stepping up and down on one or two steps. The important thing is to work these exercises into your daily routine. Many of these balance challenges also work well as a great “mini-break”, especially if you have a desk job.
Re-test your balance skills once one or two weeks and see if you can improve your time. You will be surprised how quickly and how much you can improve your balance skills and how much steadier it can make you feel in your everyday activities. Fall prevention starts with knowing your current abilities, and re-testing keeps you motivated!
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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.